Diagnosis and Management of Conversion Disorder with Hyperglycemia
This patient requires immediate blood glucose management targeting 140-180 mg/dL while simultaneously pursuing a diagnosis of conversion disorder through systematic exclusion of organic neurological causes. 1, 2
Immediate Glucose Management
The blood sugar of 180 mg/dL represents moderate hyperglycemia that warrants treatment to prevent complications and potential worsening of neurological symptoms:
Monitor blood glucose every 4-6 hours during this acute presentation to avoid both hyperglycemia and hypoglycemia, which can independently cause dizziness, headache, and balance disturbances. 1, 2
Target glucose range of 140-180 mg/dL is recommended for non-critically ill patients, as this range improves outcomes without increasing hypoglycemia risk. 1, 2
Initiate insulin therapy if glucose persistently exceeds 180 mg/dL, using a basal-bolus regimen rather than sliding scale alone, which is ineffective. 1, 2
Avoid overly aggressive glucose control (targeting <140 mg/dL), as tight control increases hypoglycemia risk, which can mimic or worsen neurological symptoms including dizziness, confusion, and loss of balance. 1, 2
Diagnostic Approach to Conversion Disorder
The diagnosis of conversion disorder requires systematic exclusion of organic causes through specific clinical assessments and targeted investigations. 3, 4
Key Clinical Features to Assess
Look for inconsistency in the neurological examination - symptoms that vary with distraction, change with different examiners, or demonstrate non-anatomical patterns are highly suggestive of conversion disorder. 5
Assess for abnormal illness behavior including la belle indifférence (inappropriate lack of concern), dramatic or flamboyant presentation, and symptoms that worsen with observation. 5, 6
Document specific characteristics of the dizziness and balance disturbance - conversion typically presents with bizarre gait patterns that defy anatomical localization, often with dramatic near-falls without actual falling. 4, 6
Evaluate the temporal headache pattern - conversion headaches often have atypical features, vary dramatically in intensity, and may not respond to typical analgesics. 4
Essential Investigations to Rule Out Organic Disease
Obtain cranial imaging (CT or MRI) to exclude stroke, hemorrhage, or mass lesions that could explain the dizziness, headache, and balance disturbance. 3, 4
Check complete metabolic panel to rule out electrolyte disturbances, renal dysfunction, or other metabolic causes of neurological symptoms. 2
Assess for hypoglycemia (glucose <60 mg/dL) as a potential contributor, though the current glucose of 180 mg/dL makes this unlikely. 1, 7
Psychosocial Assessment
Identify recent stressors including school/work stress, family changes, or recent medical procedures, as these are common precipitants in conversion disorder. 4
Screen for family members with similar symptoms or medical conditions, as modeling of illness behavior is frequently observed. 4
Evaluate for secondary gain - though patients are not consciously feigning, there may be unconscious benefits from the sick role. 5
Management Strategy
Once organic causes are excluded, provide clear explanation to the patient that symptoms are real but not due to structural disease, emphasizing the brain-body connection. 5
Communication Approach
Explain that the symptoms are genuine and not "all in their head," but represent a disconnect between brain signals and body function. 5
Avoid discussing feigning or malingering even if suspected, as this damages the therapeutic relationship and is generally counterproductive. 5
Be receptive to discussing psychological factors if the patient is open to this, but do not force psychological explanations if the patient resists. 5
Treatment Interventions
Arrange psychiatric or psychology consultation for cognitive-behavioral therapy or cognitive-analytical therapy, which have demonstrated success in conversion disorder. 8
Provide reassurance and normalize symptoms while setting expectations for gradual improvement with appropriate therapy. 8, 4
Consider admission if symptoms are severe or multiple, as structured inpatient management may facilitate diagnosis and initiate treatment. 4
Common Pitfalls to Avoid
Do not assume conversion disorder without completing organic workup - neurological conditions like multiple sclerosis have frequently been misdiagnosed as conversion disorder. 6
Do not ignore the hyperglycemia - elevated glucose can independently cause or worsen neurological symptoms and must be addressed regardless of the conversion diagnosis. 1
Do not confront the patient about psychological causation prematurely - this typically results in patient defensiveness and treatment refusal. 5
Do not discharge without follow-up plan - conversion disorder requires ongoing psychiatric/psychological care and medical monitoring. 8, 4