Ms. A displays some psychomotor retardation. She reports her mood as tired, and her affect is flat and mood incongruent. She is alert and oriented to person only; not to place, time, or situation. She can do a simple spelling task, perform 5-minute recall of 3 words, complete serial 3 subtractions, repeat phrases, read aloud, focus on a coin task, and name simple objects. She does not compare similar objects or answer simple historical or factual questions.
Ms. A replies “I don’t know” to most historical questions, such as her birthday, favorite color, and family members; she does not answer when asked how many legs a dog has, who is the current or past president, what month the Fourth of July is in, or when Christmas is. She can complete some memory tasks on the Mini-Mental State Examination, but does not attempt many others. Ms. A says she is upset about her memory deficit, but her affect was flat. Her mood and her affect were incongruent. She describes a vision of a “girl with black holes [for eyes]” in the corner of her hospital room telling her not to believe anyone and that the interviewers are lying to her. Also, she reports that “the girl” tells her to hurt herself and others, but she is not going to act on the commands because she knows it is not the right thing to do. When we ask Ms. A about a history of substance abuse, she says she has never heard of drugs or alcohol.
Overall, she displays multiple apparent deficits in declarative memory, both episodic and semantic. Regarding non-declarative or procedural memory, she can dress herself, use the bathroom independently, order meals off the menu, and feed herself, among other routine tasks, without difficulty.
According to Ms. A’s mother, Ms. A has shown a decline in overall functioning and personality changes during the past 5 months. She started to cut herself superficially on her forearms 6 months ago and also tried to change her appearance with a new hairstyle when school started. She displayed noticeably intense and disturbing writings, artwork, and conversations with others over 3 to 4 months.
She started experiencing seizures, with 3 to 4 seizures a day; however, she could attend sleepovers seizure-free. She had prolonged periods of seizures lasting up to an hour, much longer than would be expected clinically. She also had requested to go to the cemetery for unclear reasons (because the spirit wanted her to visit), and was observed mumbling under her breath.
Six years ago, Ms. A’s 6-year-old sister tried to suffocate her infant brother. Child protective services was involved and the sister was hospitalized in a psychiatric facility, where she was given a diagnosis of bipolar disorder; she was then transferred to foster care, and later placed in residential treatment. Her mother relinquished her parental rights and gave custody of Ms. A’s sister to the state.
Ms. A’s mother has a history of depression, but her younger brother is healthy. There is no history of autism, attention problems, tics, substance abuse, brain tumor, or intellectual disabilities in the family.
Which diagnosis does Ms. A’s presentation and history suggest?
a) dissociative amnesia
b) factitious disorder imposed on self
c) conversion disorder (neurological symptom disorder)
d) psychosis not otherwise specified
e) malingering
The authors’ observations
The history of unwitnessed seizures, sudden onset of visual hallucinations, and transient amnesia points to a possible postictal cause. Selective amnesia brings up the question of whether psychological components are driving the symptoms.
Her psychotic symptoms appear to be mediated by anxiety and possibly related to the trauma of losing her only sister when her mother relinquished custody to the state; the circumstances might have aroused feelings of insecurity or fear of abandonment and raised questions about her mother’s love toward her. Her sister’s abuse by a family member might have created reticence to trust others. These background experiences could be intensely conflicting at this age when the second separation individuation process commences, especially in an emotionally immature adolescent.
OUTCOME Medication change
The neurology team recommends discontinuing levetiracetam because the visual hallucinations, mood disturbance, and personality change could be adverse effects of the drug. Because of generalized uncontrolled body movements with staring episodes and unresponsiveness, an EEG is ordered to rule out ongoing seizures.
Ms. A recognizes the psychosomatic medicine team members when they interview her again. The team employs consistent reassurance and a non-confrontational approach. She spends 3 days in the medical unit during which she reports that the frequency of visual and auditory hallucinations decreases and her memory symptoms resolve. Her 24-hour EEG is negative for seizure activity, and the 24-hour video EEG does not show any signs of epileptogenic foci. Ms. A’s family declines inpatient psychiatric hospitalization.