On this placement on an obstetric ward, I’ve come across no less than 3 conversion disorder diagnoses! Well, even more confusing, POTENTIAL conversion disorder. For those of you who don’t know what that is, it’s basically a presentation of physical symptoms like intention tremor, visual deficits, loss of muscle strength or loss of balance thought to be mediated by psychological processes. So, nothing found on blood tests or MRI. It is generally diagnosed by psychiatric review. One of them very kindly declined a psychiatric review, without which you are a bit restricted in diagnosing conversion disorder.
It was very confronting for me at first. We have been trained to look for physical symptoms, and analyse the presenting information to form a problem list and a treatment plan. It’s confusing and frustrating to not be able to make sense of anything you see because it doesn’t necessarily add up.
However, upon assessment, it remains relatively easy to find impairments that you CAN have a positive effect on, and determine their functional mobility. You give them strengthening exercises, and lo and behold, they become stronger and it becomes easier to walk. As a result I’ve had 2 of my 3 conversion syndrome patients tell me or the doctor that the physios are the only ones who believed them. I reflected on this and realised that maybe it was more a case of “the physio was someone who was able to make a difference regardless of the diagnosis”.
As my supervisor said to me, at the end of the day, the diagnosis makes little difference to the physio. We effectively go in and look at the presenting symptoms and devise treatments and/or strategies for what we see. Regardless of the reason, if the patient is 2 assist, then she is 2 assist. Treatment and management are targeted accordingly. I felt this was an important point to remember. I don’t discount the fact that diagnosis is essential for correct treatment and management in a large proportion of cases, if nothing else for safety reasons. But I think it is valuable to remember that a physiotherapist still has a potential to make a difference without a clear physical or organic diagnosis. I really felt that this concept was empowering, because it made me realize that when I am a new grad, and I certainly won’t have all the answers, if I use my head and treat what I see, I still have potential to make a difference. The best part of this situation for me was how both patients felt we were their ally, simply because it didn’t appear to matter to us what their diagnosis was, in order for us to make a difference.
I know this seems painfully obvious to some of us, but it really brought home the message we are taught in musculo. We often refer to a diagnosis of non-specific LBP, and are yet able to treat this, as long as we 1) rule out red and yellow flags, and 2) treat what we see. This concept can be viewed more globally as well!
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2 comments:
Hey Beni, on my neuro OP placeent, one of the physios had a patient with suspected conversion disorder. Its really interesting that a previous stressful life event can be manifested as physical symptoms. I also found it interesting that you must treat a patient who exhibits stroke symptoms, without having had a stroke, as though they are a stroke patient. You are not allowed to show any bias against them. From my reading, these patients do not respond well to being told it's all in their head.
No, yeh fair enough. There's a very high risk that they won't respond well to that. I guess this is like what we learned with stroke patients who have a neglect or an agnosia. Gentle confrontation at some point, MAY be necessary for the patient. It is probably not necessarily our responsibility to do this, but as I said in my next blog, sometimes the patient refuses psychiatric review and they won't ever be told this (at least for this episode, during this hospital stay). I feel a sense of duty to have a go in at least gently pointing out to the patient that psychological intervention may help them. Upon thinking about it, I felt the only way I felt comfortable and tactful was by highlighting that just because someone is suggesting psychological intervention does NOT imply that it is "all in their head", and that the implication that it is in their head does not suggest that it is within the patient's control or consciousness.
By the way, I don't really know the rules about commenting on my own blogs, so this doesn't count as one of my comments.
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