Cushing’s Disease Presenting with Functional Neurological (Conversion) Disorder 2023 Ashrafzadeh et al

[Andy]

While psychiatric manifestations are common in patients with Cushing’s syndrome (CS), to our knowledge, there are no reported cases of CS presenting with functional neurological disorder (FND), a neuropsychiatric condition in which patients experience neurological symptoms, such as motor dysfunctions, sensory symptoms, speech disorders, or nonepileptic seizures, in the absence of neurological disease.

Here, we report a case of a complex patient with Cushing’s disease who presented with multiple FND symptoms including nonepileptic seizures, bilateral lower extremity paralysis, decreased finger flexion resulting in limited hand function, and stuttering. This case illustrates a rare psychiatric manifestation of CS presenting as multiple neurological complaints. Furthermore, we elucidate how a multidisciplinary treatment approach improved our patient’s FND symptoms.

Open access, https://www.hindawi.com/journals/crips/2023/1662271/

 

[Arnie Pye]

Here, we report a case of a complex patient with Cushing’s disease who presented with multiple FND symptoms including nonepileptic seizures, bilateral lower extremity paralysis, decreased finger flexion resulting in limited hand function, and stuttering. This case illustrates a rare psychiatric manifestation of CS presenting as multiple neurological complaints

I get the impression that the authors looked up a list of symptoms for Cushing's on wikipedia then declared any other symptoms the patient suffered from as FND.

What would be more useful and less sadistic is for the patient to be treated for CS, get their thyroid checked, and get any nutrient deficiencies fixed then find out which symptoms still exist.

I don't normally stutter. But there have been occasions when I do when my thyroid is untreated or under-treated, and when I've been low in various nutrients, or when I'm so out of energy I can barely talk. I don't think this should imply that I have FND.

There is a relationship between cortisol levels and thyroid hormone levels, and thyroid issues affect the gut and nutrient absorption too - but this is rarely or never acknowledged by doctors.

decreased finger flexion resulting in limited hand function

So, someone has stiff fingers, and this is a symptom of FND? Medicine has gone mad.

My bold :

While the etiology of FND is unclear, it is often associated with a psychological stressor, and recent research has identified that patients with FND demonstrate abnormal stress response and have elevated stress biomarkers levels, including cortisol [13].

If anyone had to use a short sentence to describe CS it would be something like :

"CS is caused by patients having too much cortisol."

But the authors seem to be saying that CS may be caused by FND.

...

There are also mentions of the patient having hypokalemia (although I think it is mild) - and that can do unpleasant things to muscle function even when it is mild. One thing I didn't see in the paper is any reference to treating his low potassium and what effect that had on his muscle function. In fact, immediately after mentioning the low potassium they mention giving him a tranquiliser, not potassium.

After receiving 2 mg lorazepam, he regained the ability to follow simple commands and to communicate, although with significant speech latency and hypoverbality.

Psychiatry was consulted because the patient endorsed suicidal ideation.

The patient was a 28-year-old man who was bed-bound and could hardly move his lower body. Feeling the way he did isn't surprising.

I wonder if the stuttering mentioned is anything to do with his muscle function problems - and, naturally, once psych got involved he was put on an anti-psychotic - and they can cause huge problems with movement.

This just stunned me - my bold:

One year prior to admission, the patient appeared to have progressive extremity weakness and could not control the lower extremities. The patient was diagnosed with Cushing’s disease in the outpatient setting but did not receive treatment due to concurrent onset and rapid worsening of psychiatric symptoms including depression with anhedonia, poor oral intake, memory impairment, and suicidal ideation resulting in a five-month admission to a med-psych hospital.

So, this poor man had Cushing's diagnosed a year before, which is known to cause symptoms that appear to be psychiatric, and he wasn't treated for the CS because he had psychiatric symptoms? !!!!!!

Given history obtained and physical appearance notable for central and facial adiposity, dorsal fat pad, striae, ecchymoses, and thinned skin, psychiatry advocated for workup of Cushing’s disease.An endocrinology consult guided further investigations.

Hallelujah! Finally!

The patient’s 24-hour urine cortisol level was extremely elevated to 1767.4 mcg/24 hr (normal: <50 mcg/24 hr), confirming a diagnosis of CS. In addition, serum cortisol values were elevated to 31.6 mcg/dL in the morning and 23.1 mcg/dL in the evening. Further workup revealed that plasma ACTH level was also increased to 119 pg/mL (normal: 6-50 pg/mL). An MRI of the sella turcica was ordered and showed a  mm pituitary microadenoma concerning for an ACTH-secreting tumor (Figure 1), resulting in a diagnosis of Cushing’s disease.

After treatment for his CS his symptoms started reducing and disappearing.

Psychology, physical therapy, and occupational therapy were also involved. The patient regained hand function, including the ability to eat independently and to write using a pen. Furthermore, after being bedbound for eight months, the patient was once again able to stand up and take steps with assistance. Depressed mood, anhedonia, and suicidal ideation decreased as the patient’s functional symptoms improved.

.

I am amazed that anyone published this case study. It is indicative of a total failure of the medical profession that almost paralysed a young man for a year. The authors should be embarrassed to publish this.

The only benefit to publishing this is it gives information to the medical profession on what symptoms they might see in neglected CS.

 

[rvallee]

This is like a parody of bad science. The issue isn't with the ideologues anymore, it's with a system that has given up and enables and rewards pseudoscience.

A profession so deep in crisis it can't even see it has problems at all, is in denial it can even do any wrong.

 

[Hutan]

I am amazed that anyone published this case study. It is indicative of a total failure of the medical profession that almost paralysed a young man for a year. The authors should be embarrassed to publish this.

Indeed. What a horrific situation.

 

[Hutan]

Thinking about this over breakfast, I feel infuriated at the failure of the health system to care for this person.

@Arnie Pye described what happened really well.

A diagnosis of CS may be overlooked in patients presenting to the hospital with nonspecific psychiatric symptoms given that CS is often associated with more visible physical changes, including weight gain, fatty tissue deposition, muscle weakness, striae, thinned skin, easy bruising, acne, and hirsutism, as well clinical changes such as hypertension and glucose intolerance

Well, fair enough, a diagnosis of Cushings might missed for a while if the patient just has non-specific psychiatric symptoms and doesn't have the typical physical signs. But, this patient did have those physical signs in spades. He was even diagnosed with Cushings and had it in his medical notes! But he still got dumped in a psychiatric hospital for 5 months, with no treatment for the underlying medical problem. He started having "seizure-like activity" but there was no investigation of that, an investigation that might have found the tumour in his head. And then, he was discharged to a nursing facility, with the Cushings still on his medical notes and still untreated. He only ended up in the hospital the authors work at because he became even more ill.

This is not in some health system in a poor country - this is presumably in California.

Sahar Ashrafzadeh,1Maria Theresa Mariano,1,2and Saba Syed1,2
1David Geffen School of Medicine, University of California, Los Angeles, CA, USA
2Department of Psychiatry and Biobehavioral Sciences, Olive View-UCLA Medical Center, Sylmar, CA, USA

The neuropsychiatric manifestations of CS include depression, emotional lability, sleep disturbance, memory impairment, anxiety, panic disorder, mania, psychosis, and catatonia [8, 18, 19]. Psychiatric manifestations are very common among patients with CS, with 55-81% having depression, 12% having anxiety, 3-27% experiencing hypomania or mania, and 8% experiencing psychosis [18]. Furthermore, there have been reported cases of patients with CS initially presenting to the hospital due to psychiatric manifestations or catatonia [2–7]. Importantly, while there have been reported cases of depression, psychosis, and catatonia being cured after treatment of CS, studies have shown that neuropsychiatric symptoms may persist for at least one year in some patients despite medical or surgical treatment of CS leading to normalization of cortisol levels [10]. This may be attributed to anatomical and functional changes in the brain, including brain atrophy and loss of hippocampus volume, which can contribute to depression and cognitive impairment

I'm left feeling amazed at the depth of these people's belief in the concept of conversion disorder. They accept that Cushings can cause psychosis and catatonia, but they refuse to consider the possibility that seizures and limb weakness might be due to the underlying disease and/or the medications this man has been on.

It seems, even though the Cushings syndrome diagnosis was in this man's medical notes and even though he had physical signs of Cushings, that it then took some time at the second hospital and the suggestion of a psychiatrist before investigations related to that diagnosis were started and an endocrinologist became involved.

I wonder what the point of this case study was - is it something prepared as 'arse-covering' for the second hospital?

I note that the medical team seem to have lost contact with the patient, and that the authors did not have the consent of the patient to write about him or to publish the MRI image of his brain:

This case report is limited by the unavailability of information on the outcome of the patient’s pituitary resection surgery that was performed at an outside hospital as well as the lack of data on the improvement or progression of his FND after discharge. However, strengths of this case report include our ability to closely monitor his CS, FND, and psychiatric symptoms over the course of his two-month hospitalization as he received interdisciplinary care from multiple specialists and allied health services.

Written consent was not obtained from the patient as there is no identifiable data included in this case report.

To which I can only say 'good on the patient for getting out of there'. I hope he found some respectful and competent care and that the removal of the tumour resolved his medical issues. I reckon there are grounds for a number of court cases in that account.

Prior to these changes, the patient did not have any history of depression, substance use, or other psychiatric illness, and there was no known family history of psychiatric disorders.

If it can happen to this young man in California, presumably it can happen to anyone. Imagine the outcome if he did have a history of substance abuse and didn't have medical insurance.

 

[Arnie Pye]

I reckon there are grounds for a number of court cases in that account.

I hope the hospitals and doctors involved in this man's "care" and who ignored the serious symptoms and diagnoses he had are sued for a huge amount of money for malpractice and negligence

 

[Sean]

How can any sane decent human look at this and not see an obviously appallingly cruel and easily preventable disaster?

 

[Sid]

It’s so strange that they published this. I hope he sues everyone involved in his “care” for malpractice.

 

[rvallee]

I wonder what the point of this case study was - is it something prepared as 'arse-covering' for the second hospital?

Reasonable. One of the only good features of the US health care system is tort. Likely this makes it impossible to make a case since there can be a medical "expert" to dismiss the case on grounds of it being a conversion disorder case study.

Maybe not the only reason, but this is almost academic DARVO. They screwed up big time, and instead of accepting responsibility, they covered it up and blamed it on the patient.

Not the first time either. I'm pretty sure that an in-depth investigation, basically impossible, would find loads of cases like this. Seems like the only purpose of the conversion disorder is to harm people, sometimes twice over.

 

[Amw66]

Perhaps one for Scott Simpson s medical errors series ?

 

[MEMarge]

Perhaps one for Scott Simpson s medical errors series ?

@Joan Crawford