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Thursday, December 7 • 3:35pm - 3:55pm
Seeing Parades After PNES: A Delirium-Like Presentation of a Conversion Disorder in a Pediatric Patient

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Background: Psychiatric disorders are common in children and adults with functional neurologic disorders (FND). Adults with FND often have comorbid depression, generalized anxiety disorder, and PTSD, while children with FND more commonly carry diagnoses of adjustment disorders, somatic symptoms and related disorders, and neurodevelopmental disorders (Patron, 2022). Researchers have long hypothesized a link between conversion disorders and trauma and studies have shown that stressful life events and maltreatment, especially emotional neglect, are more common in people with FND than healthy controls with a stronger association for childhood onset FND (Ludwig, 2018). Case: A 12-year-old girl with major depressive disorder (MDD) and PTSD initially presented with acute onset seizures, altered mental status (AMS), and visual hallucinations concerning for encephalitis. Structural and infectious etiologies was ruled out with CT, MRI, and LP. She was briefly treated for autoimmune encephalitis with IVIG and corticosteroids, which were discontinued when urine toxicology returned positive for Ecstasy, a known cross reactant of Wellbutrin and explanation for her seizures and AMS. She eventually admitted to intentional ingestion and was transferred to inpatient psychiatry. Three days after discharge from inpatient psychiatry, she re-presented after an episode concerning for psychogenic nonepileptic seizures (PNES) at school. While in the ED, she developed acute confusion, agitation, vivid visual and auditory hallucinations concerning for delirium. Vitals and CBC were normal, and toxicology was negative. She was discharged 24 hours later after delirium had resolved. She then re-presented three weeks later with increased sleepiness and making nonsensical statements but was otherwise cognitively intact. Overall, this presentation is consistent with a FND including PNES and delirium-like symptoms in the setting of PTSD.Discussion: Conversion disorders can present with a variety of neurologic symptoms. When our patient presented with AMS following a PNES episode, we had to evaluate whether her symptoms were likely due to another intentional ingestion of Wellbutrin or delirium from an unknown cause. We felt comfortable ruling out ingestion after speaking with the patient and family. However, we struggled to make sense of the cause of acute delirium. When the patient re-presented again with behavioral changes, we concluded that her previous delirium was likely part of a conversion disorder. This case suggests that delirium-like presentations can be a component of FND symptoms in patients with underlying MDD and PTSD. Psychiatrists should consider conversion disorders in their differential of causes of delirium, especially in pediatric patients with other comorbid psychiatric diagnoses.Conclusions: Conversion disorders may also include delirium-like presentations. When evaluating patients with delirium and known PTSD, psychiatrists should consider the possibility of a conversion disorder.

Learning Objectives:
  1. Identify presentation of functional neurological disorders.
  2. Understand how PTSD and conversion disorders can present like delirium.
  3. Review diagnostic criteria for autoimmune encephalitis.

avatar for Meghan Schott, DO, FAPA

Meghan Schott, DO, FAPA

Medical Director of Psychiatric Emergency Services, Children's National
Meghan Schott, DO, FAPA attended Oberlin College and University of North Texas-Health Science Center for medical school. She completed residency training at Allegheny General Hospital in Pittsburgh and Northwestern University/Lurie Children’s Hospital of Chicago for her child psychiatry... Read More →

Thursday December 7, 2023 3:35pm - 3:55pm PST
Vendôme A