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INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 33(3) 317-322, 2003
PSYCHOGENIC COMA: CASE REPORT
CYNTHIA L. BAXTER, MD
WILLIAM D. WHITE, MD
University of Calgary, Alberta, Canada
ABSTRACT
Coma is present when the patient appears asleep, is unrousable, and
unresponsive. Where no underlying medical condition is found, the role of
the psychiatrist may become prominent. We present a clinical case and review
the literature on psychogenic coma. According to DSM-IV-TR, psychogenic
coma is a dissociative disorder not otherwise specified. Management is
largely supportive. Principles include speaking in a reassuring manner and
avoiding repeated painful stimuli. Education of family and other professionals
that symptoms are real and not consciously feigned may be important. There
may be a short-term role for anxiolytic and/or antipsychotic medication to
assist return to consciousness.
(Int’l. J. Psychiatry in Medicine 2003;33:317-322)
Key Words: pseudocoma, dissociative disorders, psychogenic coma
INTRODUCTION
Hospital psychiatrists frequently encounter patients with altered levels of
consciousness in the emergency department (ED) and on medical and surgical
wards. Typically this involves delirium or the effects of various substances. Rarely
are psychiatrists involved in the initial management of a comatose patient. Coma is
present when the patient appears asleep, is unrousable, and is unresponsive [1].
317
Ó 2003, Baywood Publishing Co., Inc.
The role of a psychiatrist necessitates a secondary role as medical management of
the coma etiology and sequelae is a high priority. However, there are cases in
which no medical condition can be found to account for the coma and the role
of the psychiatrist becomes prominent.
Comas with a psychological etiology have been called a number of names
over the years, including hysterical coma, functional coma, simulated coma,
pseudocoma, conversion coma, and nonorganic coma to name a few. These names
are not helpful in differentiating consciously feigned presentations (malingering
or factitious) from involuntarily produced comas. According to the DSM-IV-TR,
involuntarily produced comas are specifically mentioned in the diagnostic criteria
for dissociative disorder not otherwise specified (NOS) [2]. Dissociative disorders
occur when there is a disruption of the integrated functions of consciousness,
memory, identity, or perception. Specifically, the criteria for dissociative disorder
NOS include “loss of consciousness, stupor, or coma not attributable to a general
medical condition.” This is in contrast to conversion disorders, which affect the
voluntary motor and sensory systems.
A review of the literature via MEDLINE from 1966 through to January 2003
(using keywords pseudocoma, psychogenic coma, dissociative coma, psycho-
logical coma, hysterical coma, functional coma, simulated coma, conversion
coma, dissociative disorders and coma, and nonorganic coma) failed to discover
any relevant papers in the psychiatric literature. Instead, the search revealed a
small number of psychogenic coma cases reported in the anesthesia and surgical
literature, with the majority representing females failing to awaken postopera-
tively [3-8]. Psychiatric diagnoses for most cases were either not given or used
inaccurate psychiatric terminology. This is somewhat disconcerting as psychia
-
trists are the most likely consultants to be asked to manage such cases, albeit
rare as such cases may be. The case presented here may represent the first reported
case of coma due to dissociative disorder NOS in the recent psychiatric literature.
Further, this case appears to be unique as the patient was male, had a spontaneous
onset (not postoperatively), and there was a family history in a paternal uncle
of the same disorder.
CASE REPORT
A 20-year-old Caucasian male was brought to the ED via ambulance after being
found unresponsive. The patient lived with three roommates and worked full time
in his father’s window tinting business. The previous evening he had been out with
friends where he had “a few beers” and “a little weed.” The patient returned home
with his friends at about 4:00
A.M. At home he took a tub of ice cream from the
freezer and walked out of the house. Shortly after, his friends went to his parked
car where they found him “asleep at the wheel” with the ignition off. They
attempted to rouse him without success. He was carried into the house and left
“sleeping” on the living room floor. After several hours he remained unresponsive.
318 / BAXTER AND WHITE
Later in the morning his girlfriend arrived and could not wake him; she telephoned
the patient’s father who called 911.
In the ambulance, the patient’s heart rate was 72-90 beats per minute, blood
pressure was normal, O
2
saturation on room air was 97%, and he was afebrile.
Respirations were easy. Skin was warm and dry. Radial pulses were strong.
There was no response to verbal stimuli and he withdrew from painful stimuli.
His eyelids fluttered on confrontation and his eyes rolled back on passive
eye opening. There was no incontinence and a glucose chemstrip measured
5.3 mmol/L. There was no significant medical history. He was on no medications
and had no allergies.
In the ED, the patient became unresponsive to pain and had a Glasgow coma
scale score of 3. Screening physical exam was normal. Blood tests including a
CBC, glucose, electrolytes, and renal function were normal. Arterial blood gases
were normal, as was urinalysis. EKG revealed normal sinus rhythm initially, then
sinus bradycardia. Urine toxicology was positive for cannabinoids. CT scan of the
head was normal. The emergency physician’s diagnosis was “coma NYD” and a
neurology consultation was requested. The consulting neurologist’s report noted
that brushing the eyelashes elicited eyelash fluttering and the patient resisted
passive eye opening. When the patient’s arm was held vertically above his head
and dropped, the arm fell to the side instead of dropping to the face. Cold water
caloric testing was performed with ice water irrigation of the auditory canal
producing a normal physiologic response of nystagmus to the opposite side, but no
other reaction was visible from the patient. An EEG was considered by neurology,
but felt to be unnecessary. The neurology diagnosis was “psychogenic unrespon-
siveness” and a psychiatry consultation was sought. The patient was admitted
to a medical ward for nursing care with IV fluids and a Foley catheter with
psychiatry assisting in management.
Further history revealed the patient had experienced a number of significant
stressors over the previous six to eight weeks. His family and girlfriend described
him as a “good kid” who was quite sensitive, but was immature and tended
to react in the moment. In the months prior he had been pulled over by the
police for speeding and did not have insurance. Afterwards, he had not followed
through with the local police office and knew the police had come to his parents
home looking for him. His longstanding tense relationship with his father,
whom he worked for, was also worsening. He had recently been fighting with
his girlfriend of two to three months over her “catching him” with his ex-girlfriend
exchanging gifts. Then two days before his presentation in the ED, he and his
roommates were given an eviction notice for unpaid rent.
There was no history of psychiatric illness. The patient was drinking beer
several nights per week and socially using cannabis. Regarding family psychiatric
history, according to the parents the patient’s paternal uncle “did the same thing”
about 20 years ago. The family was unaware if the patient knew about his uncle’s
history: the uncle had lost consciousness and was unresponsive for a few days
PSYCHOGENIC COMA / 319
before his (the uncle’s) wedding. No etiology was ever identified and the uncle’s
episode resolved with supportive care.
On admission, the patient was started on intravenous lorazepam Q.I.D., in
addition to his supportive care. He remained unresponsive to painful stimuli, but
was noted to occasionally move spontaneously in bed, turning over. On the second
day, low dose intravenous haloperidol q6h was added. Forty-eight hours after
his initial presentation to the ED, the patient began to have intermittent periods of
consciousness where he would open his eyes, could follow simple commands, and
answer questions with nonverbal signals and limited verbal responses. Between
these periods, he would revert back to his previous comatose state. By the evening
of the third day he could converse and stated he felt tired. By the morning of the
fourth day he was completely alert and had no complaints. He denied any
recollection of the previous few days and last remembered going to his car with
the intent to drive to a convenience store. A review for psychiatric symptoms
was negative. Admission to the psychiatric unit was not deemed necessary and
the patient was offered outpatient follow-up. He was discharged on the fourth
day with no medication.
DISCUSSION
Coma is most often due to significant medical illness; as such, a diagnosis of
psychogenic coma needs to be a diagnosis of exclusion, although there may be
certain clinical features that suggest the diagnosis. Often listed as a potential cause
for coma in textbooks, it usually comes at the end of the differential lists, with such
a small incidence that percentages are not given [9]. In a review of 405 patients
with psychogenic dysfunction of the nervous system, only one of those patients
had a coma [10].
Diagnosis of psychogenic coma may be suggested by a clinical history where
the change in level of consciousness was precipitated by stress and where the
patient slumps to the floor without hitting his head [9]. Often there is an observer
present. On clinical exam, several eye features may be noted [4, 8, 9]. The patient
may have active resistance to passive opening of the eyelids, the eyelids tend to
close abruptly and completely when the lifted upper eyelid is released (rather than
slowly, asymmetrically and incompletely in a coma due to organic causes). The
eyelids may flutter when the eyelashes are stroked gently. Spontaneous eye
movements tend to be rapid and jerking rather than slowly roving. The eyes may
be rolled back (“Bell’s phenomenon”) or deviated in one particular direction,
commonly away from the examiner or down. Other clinical features may include
active resistance on examining tone or cogwheeling resistance with sudden
“giving-away” phenomena. The patient may occasionally make voluntary
movements or change body position in bed. The “hand drop test” is where
the patient’s arm is held above the face in the supine position and released. In
a coma attributable to a general medical condition or the direct effects of a
320 / BAXTER AND WHITE
substance, the hand tends to fall on the face, whereas in psychogenic coma it is
noted that the hand tends to fall to the side, though there is some controversy
over the validity of this test [11].
The use of repeated painful or noxious stimuli is strongly contraindicated in
psychogenic coma [11, 12]. There may be severe psychological distress over
-
whelming the patient and it is important to remain sensitive in allowing the patient
to gently recover. In one case, physicians were so insistent and persistent in
trying to force the patient to awaken they went as far as occluding his airway
for 60 seconds after “vigorous” painful stimuli was unsuccessful in eliciting a
response. Physicians in such cases may have an underlying assumption that
the patient has conscious control over the symptoms, and thus engage in a battle to
outwit and “win” against the patient.
Management of a coma due to dissociative disorder NOS is largely supportive.
Principles include speaking to the patient in a calm reassuring manner and
avoiding repeated painful stimuli. Education of the family and other profes-
sionals that symptoms are real and the patient is not consciously feigning may
be important. As profound psychological distress may underlie this disorder,
there may be a short-term role for medications such as anxiolytics or antipsy-
chotics to assist the patient’s return to full consciousness.
Valuable information for the future would include reliable epidemiological
data, e.g., the incidence of coma due to dissociative disorder NOS, patterns of
pre-existing and comorbid psychiatric illness, and the natural history and course
of the illness including the long-term physical and psychological outcomes for
these patients. Controlled studies of a variety of interventions (e.g., anxiolytics/
antipsychotics versus placebo, various interpersonal approaches to the patient)
would be useful to determine whether these facilitate recovery; however, such
studies would be difficult given the apparently very low incidence of the
condition.
REFERENCES
1. Yudofsky SC, Hales RE, editors. The APA textbook of neuropsychiatry and clinical
neurosciences. Washington: American Psychiatric Association, 2002, 506.
2. American Psychiatric Association. Diagnostic and statistical manual of mental
disorders, 4th ed., text revision. Washington: American Psychiatric Association, 2000.
3. Adams AP, Gorosszeniuk T. Hysteria: A case of failure to recover after anaesthesia.
Anaesthesia 1991;46:932-934.
4. Maddock H. An unusual case of hysterical postoperative coma. Anaesthesia
1999;54(7):717-718.
5. Meyers TJ. Recurrent psychogenic coma following tracheal stenosis repair. Archives
of Otolaryngology and Head and Neck Surgery 1999;125(11):1267-1269.
6. Weber JG. Psychogenic coma after use of general anesthesia for ethmoidectomy.
Mayo Clinic Proceedings 1996;71(8):797-800.
PSYCHOGENIC COMA / 321
7. Albrecht RF, Wagner SR, Leicht CH, Lanier WL. Factitious disorder as a cause
of failure to awaken after general anesthesia. Anesthesiology 1995;83(1):201-204.
8. Henry JA, Woodruff GHA. A diagnostic sign in states of apparent unconsciousness.
Lancet 1978;2:920.
9. Mann J. EM guidemaps—Coma. Retrieved July 16, 2002 from URL.
http://emguidemaps.homestead.com/files/coma.html
10. Shaibani A, Sabbagh MN. Pseudoneurologic syndromes: Recognition and diagnosis.
American Family Physician 1998;57(10):2485-2494.
11. Jackson AO. Faking unconsciousness. Anaesthesia 2000;55(4):409.
12. Padkin A. Avoiding unnecessary trauma in the differential diagnosis of coma.
Anaesthesia 1999;54(11):1126-1127.
Direct reprint requests to:
Dr. Cynthia Baxter
Department of Psychiatry, Foothills Hospital
1403 29th Street NW
Calgary, AB T2N 2T9
e-mail: cynthiabaxter@shaw.ca
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