Young, pregnant, ataxic—and jilted

How would you treat Ms. M?
a) destigmatize psychiatric illness and provide psychoeducation regarding treat­ment benefits
b) identify and treat any comorbid psychiat­ric disorders
c) maintain a proactive and multidisci­plinary approach that includes assess­ment of psychosocial stressors and psychodynamic factors, particularly those related to the pregnancy
d) all of the above

TREATMENT Close follow-up
The psychiatrist recommends continued close psychiatric follow-up as well as multidisci­plinary involvement, including physical ther­apy, neurology, and obstetrics.

Ms. M initially is resistant to psychiatric follow-up because she says that “people on the street” told her that, if she saw a psychia­trist, her baby would be taken away. After the psychiatrist explains that it is unlikely her baby would be taken away, Ms. M immediately appears relieved, smiles, and readily agrees to outpatient psychotherapy.

Over the next 24 hours, she continues to work with a physical therapist and her gait sig­nificantly improves. She is discharged home 2 days later with a walking aid (Zimmer frame) for assistance.

Four days later, however, Ms. M is readmit­ted with worsening ataxia. Her aunt reports that, at home, Ms. M’s regressed behaviors are worsening; she is sleeping in bed with her and had several episodes of enuresis at home.

Ms. M continues to deny psychiatric symp­toms or anxiety about the delivery. Although she shows some improvement when work­ing with physical therapists, they note that Ms. M is still unable to ambulate or stand on her own. The psychiatrist is increasingly con­cerned about her regressed behavior and con­tinued ataxia.

A family meeting is held and the psychia­trist and social worker educate Ms. M and her aunt about conversion disorder, including how some emotionally distressed women communicate their feelings or troubled thoughts through physical symptoms and how that may apply to Ms. M. During the meeting, the team also destigmatizes psy­chiatric illness and treatment and provides psychoeducation regarding its benefits. The psychiatrist and social worker also provide a psychodynamic interpretation that her ataxia could be a way of protecting herself against the abandonment she is experiencing by being left to “stand alone” by her boyfriend— as she had been when her parents sent her to the United States, and that her behavior could be her way of securing her aunt’s love and support.Ms. M and her aunt both readily agree with this interpretation. The aunt notes that her niece is more anxious about motherhood than she acknowledges and is concerned that Ms. M expects her to be the primary care­giver for the baby. Those present note that Ms. M is becoming increasingly dependent on her aunt, and that it is important for her to retain her independence, especially once she becomes a mother.

Ms. M immediately begins to display more affect; she smiles and reports feeling relieved. Similar to the previous admission, her gait sig­nificantly improves over the next 2 days and she is discharged home with a walking aid.

The authors’ observations
A broad differential diagnosis and early multidisciplinary involvement might facilitate earlier diagnosis and treatment.¹⁶ Assessment of psychosocial stressors in the patient’s personal and family life, includ­ing circumstances around the pregnancy and the meaning of motherhood, as well as investigation of what the patient may gain from the sick role, are paramount. In Ms. M’s case, cultural background, sepa­ration from her parents at a young age, and recent abandonment by her boyfriend have contributed to her inability to “stand alone,” which manifested as ataxia. Young age, regressed behavior, and her minimi­zation of stressors also point to her dif­ficulty acknowledging and coping with psychosocial stressors.

Successful delivery of the diagnosis is key to treatment success. After building a therapeutic alliance, a multidisciplinary discussion should take place that allows the patient to understand the diagnosis and treatment plan.^17,18 The patient and family should be reassured that the fetus is healthy and all organic causes of symptoms have been investigated.¹⁷ Although man­agement of conversion disorder during pregnancy is similar to that in non-preg­nant women, several additional avenues of investigation should be considered:
• Explore the psychodynamic basis of the disorder and the role of the pregnancy and motherhood.
• Identify any comorbid psychiatric disorders, particularly those specific to pregnancy or the postpartum period.
• Because of the shame and stigma associated with seeking psychiatric treat­ment during pregnancy,^10,11 it is impera­tive to destigmatize treatment and provide psychoeducation regarding its benefits.

A treatment plan can then be developed that involves psychotherapy, psychoedu­cation, stress management, and, when appropriate, pharmacotherapy.¹⁷

Providing psychoeducation about postpartum depression and other perina­tal psychiatric illness could be beneficial. Physical therapy often is culturally accept­able and can help re-establish healthy patterns of motor function.¹⁹ Ms. M’s gait showed some improvement with physical therapy as part of the multidisciplinary approach, which also should include a thorough medical workup. Appropriate psychiatric treatment can help patients give up the sick role and return to their previous level of functioning.¹⁷