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Psychogenic Coma: Case Report

  • University of British Columbia - Island Medical Program, Canada, Victoria


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, Vol. 33(3) 317-322, 2003
University of Calgary, Alberta, Canada
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
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].
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.
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.
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
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
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.
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
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
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
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.
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.
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
... Despite the causes of psychogenic coma are numerous but currently, the precise etiology is still unknown [1]. Where no underlying medical condition is found [5]. Psychiatric disorders are frequently premorbid estimates but are not required for the diagnosis [2]. ...
... Cases of the locked-in syndrome may be present with the voluntary movement of their eyes [5]. While those of psychogenic comas evince active resistance for the passive opening of the eyelids with abruptly and completely closed eyelids [5]. ...
... Cases of the locked-in syndrome may be present with the voluntary movement of their eyes [5]. While those of psychogenic comas evince active resistance for the passive opening of the eyelids with abruptly and completely closed eyelids [5]. Life-threatening causes of coma should be instantly excluded especially the unresponsive patient with inconsistent physical examination [1]. ...
Full-text available
Introduction: Psychogenic coma, generally is one of the most anxious and irritant problems in clinical medicine for all medical practitioners. Using recurrent painful or mischievous stimuli is contraindicated in a psychogenic coma. Method of study and patients: My study was technical, prospective, observational, and interventional for 321 cases. The study was conducted in a physician outpatient clinic, Fraskour Central Hospital, and Ras-Al-bar Central Hospital. The author reported the 321 cases of psychogenic coma over nearly 5 years and 7-months, started from August 07, 2015, and, ended on March 07, 2021. Three selective groups were included in the study. Three groups were selected and evaluated for safety or complications and efficacy or responses. Suggesting hypothesis: Yasser’s maneuver can regaining the consciousness in a psychogenic coma. The research objectives to evaluate this hypothesis might include: What is psychogenic coma? What is Yasser’s maneuver? How can Yasser’s maneuver do improvement of psychogenic coma? Is the study supported by past publicized literature studies? Results: The range of age in the study was 16-55 years with an insignificant P-value (0.231). There is a female sex predominance for all groups (67%). The response for the group I was: (97.35%)) vs. (85.85%)) in group II, and (81.37%) in group III. The most common associated risk factor was psychogenic hyperventilation syndrome (HVS); in the group, I was 79.6%, in group II was 78.4%, and in group III was 96.2±1.7 with no statistical significance (P-value 0.74). Conclusions: The author concluded thatYasser’s maneuver is easy, available, quick, non-costive, time-saving, and extremely safe in the psychogenic coma. Very few and mild few mild complications for this maneuver encourage the generalizing use in the psychogenic coma.
... Another case report, however, described upwards deviation of the gaze (Maddock et al., 1999). Tightly shut eyes that resist attempts at eye opening are widely accepted as a positive sign of functional coma (4/25 cases : Hopkins, 1973;Baxter and White, 2003;Haller et al., 2003;Freudenreich et al., 2007). Once they have been opened, the eyelids usually close rapidly; steady and slow eye closure occurs in organic coma states and cannot be produced voluntarily. ...
... This is obviously not helpful in more unusual cases, particularly of functional stupor, where the eyes may be open (Hopkins, 1973;Hurwitz, 2011). Fluttering eyelids have been reported by some authors (Hopkins, 1973;Maddock et al., 1999;Baxter and White, 2003), as well as eyes rolling upwards when opened against resistance (Bell's phenomenon) (Hopkins, 1973;Baxter and White, 2003;Freudenreich et al., 2007), and, rarely, light sensitivity (Hopkins, 1973;Downs et al., 2008). ...
... This is obviously not helpful in more unusual cases, particularly of functional stupor, where the eyes may be open (Hopkins, 1973;Hurwitz, 2011). Fluttering eyelids have been reported by some authors (Hopkins, 1973;Maddock et al., 1999;Baxter and White, 2003), as well as eyes rolling upwards when opened against resistance (Bell's phenomenon) (Hopkins, 1973;Baxter and White, 2003;Freudenreich et al., 2007), and, rarely, light sensitivity (Hopkins, 1973;Downs et al., 2008). ...
Full-text available
Functional coma – here defined as a prolonged motionless dissociative attack with absent or reduced response to external stimuli – is a relatively rare presentation. In this chapter we examine a wide range of terms used to describe states of unresponsiveness in which psychologic factors are relevant to etiology, such as depressive stupor, catatonia, nonepileptic “pseudostatus,” and factitious disorders, and discuss the place of functional or psychogenic coma among these. Historically, diagnosis of functional coma has sometimes been reached after prolonged investigation and exclusion of other diagnoses. However, as is the case with other functional disorders, diagnosis should preferably be made on the basis of positive findings that provide evidence of inconsistency between an apparent comatose state and normal waking nervous system functioning. In our review of physical signs, we find some evidence for the presence of firm resistance to eye opening as reasonably sensitive and specific for functional coma, as well as the eye gaze sign, in which patients tend to look to the ground when turned on to one side. Noxious stimuli such as Harvey's sign (application of high-frequency vibrating tuning fork to the nasal mucosa) can also be helpful, although patients with this disorder are often remarkably unresponsive to usually painful stimuli, particularly as more commonly applied using sternal or nail bed pressure. The use of repeated painful stimuli is therefore not recommended. We also discuss the role of general anesthesia and other physiologic triggers to functional coma.
... There are also nonpharmacological causes, such as seizure, stroke, and, in rare cases, psychogenic disease [3]. Psychogenic coma can be diagnosed as the cause when all other organic causes have been ruled out [4]. It is difficult for an anesthesiologist to immediately suspect psychogenic coma when the patient fails to regain consciousness after anesthesia, because it occurs rarely and can be diagnosed at the end of the evaluation [5]. ...
Full-text available
Background: Delayed emergence from general anesthesia is associated with life-threatening conditions with pharmacological, neurological, metabolic, and rarely, psychiatric causes. Failure to immediately recognize the cause of delayed emergence from general anesthesia may result in increased morbidity, mortality, examination costs, and physician anxiety. Case: We present the case of an elderly woman who became unresponsive after recovery from anesthesia with remimazolam and remifentanil. Physical examination, laboratory testing, and radiographic imaging did not reveal any obvious organic causes. Pharmacological or metabolic abnormalities were not found. Absence of those causes strongly suggests that prolonged unconsciousness is related to psychiatric origin. The patient spontaneously regained consciousness after 48 hours without any neurological complications. Conclusions: Anesthesiologists should be aware of the various causes of delayed recovery from general anesthesia and understand that there are psychogenic causes in rare cases.
... There have been several reports of conversion disorder in the obstetrics and anesthesiology literature following various types of procedures. [49][50][51][52] This highlights a risk of invasive procedures that is often not considered. ...
Psychogenic nonepileptic seizures (PNES) can present emergently and are often mistaken for epileptic seizures. PNES emergencies have not been well studied, and yet there are associated serious morbidities, particularly when patients are seen in an emergency setting and are misdiagnosed. PNES may be prolonged, mimicking status epilepticus, a condition we refer to as nonepileptic psychogenic status (NEPS), and patients may receive aggressive and unnecessary medical treatments that can lead to serious iatrogenic complications, including death. NEPS is also associated with an increased risk of self-harm, including suicide attempts, and may indicate a serious comorbid psychiatric illness. In addition to iatrogenic complications of PNES, accidents and injuries are an underrecognized source of morbidity. PNES may also present during medical procedures, which may not only interfere with their completion, but may alarm practitioners who, fearing liability, may initiate further medical evaluations and treatments. When PNES occur during pregnancy, patients may be misdiagnosed with eclampsia and their offspring delivered prematurely. They also risk being placed on medications that are harmful to the fetus. Increased awareness of PNES is necessary to prevent iatrogenic harm and to identify underlying psychiatric illnesses that carry their own risks. As yet, data available to guide treatment are scant, and further study is needed. © EEG and Clinical Neuroscience Society (ECNS) 2015.
Background: Psychiatric illness can mimic a comatose state. The most common is a conversion reaction resulting in a functional coma, which poses a unique diagnostic challenge to the clinician. Little is known about this condition, and the literature is limited by inconsistent terminology and by a lack of high-quality evidence. Objective: To provide a conceptual definition of functional coma, describe case examples, summarize management, and increase recognition of this often underacknowledged entity. Methods: We present two cases and provide a comprehensive review of the literature on the differential diagnosis, pathophysiology, workup, and management. Results: Functional coma is defined as an involuntary coma-like state that occurs in the absence of structural or metabolic damage to the brain and that is distinct from catatonia. This term should supplant the previous phrase of "psychogenic coma." Psychiatric disorders are frequently present premorbidly, but are not required for the diagnosis. About half of the cases occur in the perioperative setting. Physical exam can provide helpful clues, including passive resistance to eye opening or avoidance of the face with arm drop. Additional work-up, including laboratory studies, brain imaging, and electroencephalography, should be obtained but are unremarkable in functional coma. Case studies suggest that the episodes last for several hours, with a range of 45 minutes to 4 days. Treatment includes supportive management and careful psychoeducation. Conclusions: Functional coma should be conceptualized as a distinct condition from catatonia and psychogenic non-epileptic seizures. Additional clinical and translation research is needed to further explore the etiology of this condition.
Coma represents a true medical emergency. Drug intoxications are a leading cause of coma; however, other metabolic disturbances and traumatic brain injury are also common causes. The general emergency department approach begins with stabilization of airway, breathing, and circulation, followed by a thorough physical examination to generate a limited differential diagnosis that is then refined by focused testing. Definitive treatment is ultimately disease-specific. This article presents an overview of the pathophysiology, causes, examination, and treatment of coma.
Si definiscono psicogeni i deficit che non possono essere attribuiti ad alterazioni strutturali o a malattie neurochimiche note, ma che possono essere provocati da malattie psichiatriche o da simulazione [1].
Functional somatic syndrome or "psycogenic syndrome" are a group of disorders characterised by patterns of persistent bodily complaints for which no clear organic reason can be found. These conditions are common worldwide and in all areas of medicine. About one third of patients undergoing a first neurological examination do not present organic disease. Here we perform a revision of the literature to give an overview of the common "pseudoneurological" syndromes such as chronic pain, smell and taste disorders, pseudo-vertigo, pseudo-deafness, gait disorders, pseudo-paralysis, sensibility and psychogenic movement disorders, and pseudo-seizures. Aim of the review is to identify the anamnestic, clinical and semeiological features that play a key role in distinguishing organic from non-organic disorders.
Hysterical pseudo-coma corresponds to a state of clinical sleep with contrasting waking electroencephalogram. It can last several hours or even several days in the absence of an underlying organic disease. In psychiatry, this disorder is currently part of the "dissociative disorder not otherwise specified". Through this case report, we describe the evolution of a hysterical pseudo-coma that lasted four days in a 28-year-old man. The normality of biological, radiological and electroencephalographic assessments, and responsiveness of the patient during the implementation of a nasogastric tube, led us to suspect a mental origin. An adapted psychiatric care allowed the patient to recover his autonomy after three days of hospitalization. This had prevented the escalation of explorations and invasive treatments. However, the search for organic comorbidity and its management remains a priority. Copyright © 2014 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.
Dissociative disorders are defined as condition that involve disruptions or breakdowns of memory, awareness, identity and/or perception. The dental treatments of the patents with dissociative disorders have often difficulties because they show uncomfortable symptoms including unconsciousness, collapse and shiver. We presented a case of dissociative disorder that was revealed by the conditions found during the dental treatment. A 51-year-old female referred to our clinic for the removal of the inflamed implant in the anterior left side of the maxilla. The implant removal had failed because she showed a collapse and an excretion of bubbly saliva form her mouth during the treatment. Under local anesthesia the implant was removed with monitoring the general condition. During the operation she showed the same symptoms but the date of the monitoring was unchanged. After the operation she examined closely in the internal medicine and was diagnosed dissociative disorder.
Deviation of the eyes towards the ground with the patient lying on each side is proposed as a diagnostic sign in psychogenically mediated states resembling coma or epilepsy. Six cases are described in which the sign was elicited.
Hysteria as a cause of failure to recover consciousness following general anaesthesia is a rare event. This case report describes such an instance in a young, healthy 22-year-old female suffering severe dental phobia who was undergoing dental conservation. The literature is reviewed and a summary of the possible physiological mechanisms involved is given.
Failure of a patient to awaken promptly after use of general anesthesia may be due to various causes, including medication-related effects, neurologic insults, or metabolic disturbances. Herein we describe a 49-year-old woman with a history of depression, for which she was receiving treatment, who did not awaken promptly after use of general anesthesia for ethmoidectomy. Results of neurologic examinations were normal, as were laboratory tests and radiologic studies. Six hours after completion of the operation, the patient spontaneously awakened. We hypothesize that she underwent a transient, self-limited period of dissociation related to unresolved grief due to the recent death of a family member.
Physicians may encounter patients with a collection of psychologic disorders that present with neurologic symptoms or signs, yet have no identifiable structural or functional etiology within the nervous system. These disorders comprise the so-called pseudoneurologic syndromes, which can mimic almost any organic disease. A careful history and physical examination often can identify the psychologic origin of the symptoms. Presenting syndromes can include pseudoparalysis, pseudosensory syndromes, pseudoseizures, pseudocoma, psychogenic movement disorders and pseudoneuro-ophthalmologic syndromes. These presentations may be distinguished from organic disease by observing signs and symptoms or eliciting test responses that are nonphysiologic and incompatible with organic disease. Once a pseudoneurologic syndrome is identified, patients require compassionate and understanding care to resolve underlying emotional problems.
Medication, intracranial hemorrhage, infarction, infection, hypoxia, organ failure, and nutritional deficiency may cause unconsciousness following successful emergence from anesthesia. A 39-year-old woman with a history of tracheal stenosis, depression, and anxiety had complete unconsciousness on 3 separate occasions following surgical repair of her tracheal stenosis. In each case, the patient's endotracheal tube had been removed; she was alert and oriented to person, time, and place; and she was admitted to the hospital for observation. Within a few hours after the tube was removed, the patient became abruptly unconscious for periods of 36, 18, and 30 hours. Each time, the results of cardiac, pulmonary, metabolic, and neurologic examinations and radiological studies were normal. We hypothesize that the patient's apparent comas were the result of an underlying conversion disorder precipitated by unresolved psychological conflict surrounding a long history of abuse in which she was repeatedly smothered by a pillow.