Childhood Trauma and Conversion Disorder in a 16-Year-Old Boy

Abstract

To the Editor: In the early 1900s, Pierre Janet observed a relationship between conversion disorder and childhood suggesting that dissociation during trauma could be adaptive.1,2 Case report. Mr A, a 16-year-old white boy, was admitted to the hospital after 2 days of episodes of rhythmic jerking of his right upper extremity and generalized tremulous shivering movements. During these episodes, he was unable to speak but was able to follow simple commands. Pediatric neurologic consultation, including sleep-deprived electroencephalograph, ruled out organic cause for the episodes. On day 2 of the hospitalization, he began to complain of urinary retention, as well as penile and groin anesthesia. He required bladder catheterization with normal urine volumes. Psychiatric consultation was requested due to concerns that he might have conversion disorder. History revealed current treatment of attention-deficit/hyperactivity disorder with atomoxetine 80 mg, a recent diagnosis of posttraumatic stress disorder (PTSD), and mild intellectual disability. Mr A had been placed in foster care 2 months prior to admission due to physical and sexual abuse by his father, which had consisted of his father at times standing on Mr A’s penis and striking his penis with a stick as punishment. On the day his seizure-like episodes started, he had been scheduled to meet with the legal team to bring charges against his father. On interview, Mr A reported frequent thoughts of the abuse and worried that he would never be able to have children due to the trauma to his penis. In light of the neurologic symptoms, including nonepileptic seizures, urinary retention, and numbness of his genitalia, Mr A was diagnosed with conversion disorder(DSM-5 criteria). He was provided psychoeducation and supportive therapy by the psychiatric consultant, and his symptoms resolved later that day. At 9-month follow-up, Mr A was in psychotherapy and free of neurologic symptoms. Lifetime prevalence of conversion disorder ranges from 11 to 500 per 100,000 population.3 Risk factors include low socioeconomic and educational status, low psychological sophistication, and rural settings,3 all features of our patient. A review of nonepileptic seizures found nearly one-third of patients reported childhood sexual abuse.4 To our knowledge, 2 similar cases have been published. One was the case of an 11-year-old boy with urinary retention, erectile dysfunction, and penile anesthesia following circumcision, and another was of a 15-year-old girl who was sexually and physically abused by her father and presented with tremor and urinary retention.5,6 Most conversion symptoms resolve before hospital discharge, but as many as 20%–25% relapse within 1 year,7 and 4%–15% are eventually diagnosed with a neurologic disorder.8,9 It was prescient that Janet1 connected childhood trauma to transient neurologic disruptions, such as conversion symptoms. It is likely that Mr A’s recent discussions of his trauma, and court proceedings against his father, exacerbated his PTSD. Physiologically, it is plausible that overwhelming stress could increase sympathetic nervous system tone, causing transient urinary retention. Also, the “emotional numbing” often described in PTSD sufferers, and those who self-mutilate in the context of past abuse, may involve disturbances of endogenous opiates or mechanisms of auto-anesthesia that have evolved to help endure extreme pain or stress. In our case, the transient genital numbing may be a sort of “somatic flashback” to his body’s attempts to numb the pain of physical assaults on his genitals. Our patient’s prognosis is enhanced by a clearly identifiable stressor, an emotionally supportive foster parent, and initiation of trauma-focused cognitive-behavioral therapy for children with PTSD. We should be aware that conduct disorder presents in a range of different motor and sensory deficits, and that some of these symptoms may be directly related to specific traumatic or extremely stressful experiences. Identifying these connections may expedite diagnosis and treatment.