CASE REPORT

Kidney Transplant Recipient with Conversion
Disorder Treated by Electroconvulsive Therapy

Rachel Beeson a Stavros Stefanopoulos a , b Daniel Rapport1 , c and Jorge Ortiz a

Coresponding author(s): daniel.rapport@utoledo.edu

aDepartment of Surgery The University of Toledo, Health Science Campus, 3000 Arlington Ave., Toledo, OH 43614, USA,bM.D. Candidate, Class of 20XX, The
University of Toledo Heath Science Campus, 3000 Arlington Ave., Toledo, OH 43614, USA, and cDepartment of Psychiatry, The University of Toledo, Health Science
Campus, 3000 Arlington Ave., Toledo, OH 43614, USA

We describe the case of a patient with severe post-operative
conversion disorder successfully treated with electroconvulsive
therapy (ECT) with good clinical outcome. A 66-year-old Cau-
casian male presented to the emergency department (ED) with
altered mental status and was nonverbal three days after un-
dergoing an uncomplicated incisional hernia repair. He had a
past medical history of major depression with psychotic fea-
tures and generalized anxiety disorder as well as a kidney trans-
plant. He had multiple previous psychiatric hospitalizations in
the 1980s for severe depression with suicidality treated success-
fully with ECT. The patient was admitted, and a diagnosis of
conversion disorder was made. His condition deteriorated over
21 days of inpatient management and he failed to respond to
methylphenidate, aripiprazole, haloperidol, and lorazepam. Bi-
lateral ECT treatment was initiated and the patient demonstrated
a dramatic functional improvement after the first treatment. He
was discharged home after receiving 6 total treatments and con-
tinued outpatient treatments with good clinical outcome. ECT
may be considered in patients with severe conversion disorder
with a previous history of successful treatment.

conversion disorder | electroconvulsive therapy | kidney transplant

For millennia, conversion disorder has been a well-documentedphenomenon troubling medical professionals and accruing vari-
ous names over time, most notably hysteria (1, 2). Freud and Janet’s
work independently laid the foundation for the current psycholog-
ical understanding we have of the disease today (1, 3-5). Today,
the Diagnostic and Statistical Manual of Mental Disorders (DSM-
5) defines it as a psychiatric illness with symptoms affecting vol-
untary motor or sensory function that cannot be explained by an
organic medical condition and cause clinically significant impair-
ment in function (6). Making the diagnosis can present a challenge
to medical professionals. Other neurologic or psychiatric conditions
must be considered and ruled out including, non-epileptic seizures,
factitious disorder, malingering, and somatization to name a few (3,

7). The current treatment for conversion disorder is psychotherapy
as the basis, but can also include physical therapy and medications
such as SSRIs (3, 7-9). ECT is seldom used in the treatment of
conversion disorder, however this treatment has been demonstrated
in multiple case reports and case studies to have been beneficial in
refractory patients (10-13). We present the case of a patient exhibit-
ing severe conversion disorder treated with ECT resulting in good
clinical outcome.

Case Report

Patient Information

A 66-year-old Caucasian male presented to the emergency de-
partment (ED) with altered mental status 3 days after undergoing
an uncomplicated incisional hernia repair. The patient had become
nonverbal at home and was brought to the ED by his family for
evaluation. The family further elaborated on the abnormal behavior
claiming the patient had signs of paranoia, hallucinations, and dis-
organized speech. The patient had a past psychiatric history signif-
icant for major depression with psychotic features and generalized
anxiety disorder. He had a previous history of psychiatric hospital-
izations in the 1980s for severe depression with suicidality which
were successfully treated with ECT. He was subsequently main-
tained on lithium carbonate to control his psychiatric disorder. The
lithium treatment was complicated by renal failure and he received
a renal transplant in 2016 from a related living donor. He was main-
tained on anti-rejection medications thereafter. Following the renal
transplant, he was placed on aripiprazole to prevent further relapse
of his psychiatric condition. His family had not observed any other

Submitted: 01/17/202, published: 05/14/2020.

translation@utoledo.edu UTJMS 2020 Vol. 7 21–22

mailto:daniel.rapport@utoledo.edu


signs of abnormal behavior, depression, or withdrawal in the weeks
leading up to the hernia repair. However, they did report that he had
been anxious about the surgery and stated that he had had a sim-
ilar, albeit less severe, reaction following his renal transplant. On
exam in the emergency department, the patient was alert but diffi-
cult to assess given his nonverbal condition. He responded to painful
stimuli with facial grimacing. Observation of the surgical site was
unremarkable and he was afebrile. His vital signs, complete blood
count, complete metabolic panel, troponins, and creatinine kinase
were all within normal limits. Toxicology screen was negative. A
CT scan of the abdomen, pelvis, and brain did not reveal any acute
abnormalities.

Objective for Case Reporting

To present a novel case of a patient with severe conversion dis-
order treated with ECT with good clinical outcome.

Case

The patient was admitted to the inpatient psychiatric unit for
further evaluation and treatment. Aripiprazole was discontinued and
switched to haloperidol empirically because it was felt to be a more
potent antipsychotic than the low dose of aripiprazole that he was
receiving. He continued to decline. Subsequently he refused any
oral intake and by the third day he became bedbound and immobile.
Given his presentation, a diagnosis of catatonia was now entertained
considering his history of major depression with psychotic features.
However, we could not establish the diagnosis of depression since
the patient was mute. Additionally, he failed to respond to or show
any improvement after receiving a 2 mg dose of IV lorazepam.

After 3 days of management in the adult psychiatric inpatient
service, he was transferred to the medicine unit under the transplant
service and consultation liaison psychiatry was called in. A neurol-
ogy consult was placed, and EEG was performed which ruled out
status epilepticus. An MRI of the brain was unremarkable for acute
pathology. Haloperidol was discontinued and low dose aripiprazole
was restarted. Switching antipsychotics resulted in minimal im-
provement in the patient’s state, although the family reported that he
responded to them at times. This was viewed by the consult service
as being inconsistent with typical signs of catatonia. He squeezed
his wife’s hand when prompted and was able to sing simple songs
on command including happy birthday.

Aside from these isolated events, the patient remained stu-
porous, immobile, and nonverbal. There was no response to ster-
nal rubs and no demonstration of rigidity, posturing, or any other
notable mannerisms of catatonia. He did not exhibit negativism,
opposition, or inability to respond to instructions. At this point,
both his white blood cell count and body temperature were begin-
ning to rise. Ultimately, the decision to consider ECT was neces-
sary to prevent further morbidity and potential mortality. However,
both the surgeon and consultation liaison psychiatrist agreed that
the patient lacked capacity. The consultation liaison psychiatrist
called in a second psychiatrist specializing in ECT who concurred.
Before resorting to ECT, a brief trial of low-dose methylphenidate
was given in the hopes that it might activate the patient and was
gradually increased over 2 days. Shortly thereafter, the family re-
ported that he appeared more anxious and uncomfortable at which
point that was discontinued. After 3 weeks in the hospital with no
improvement and increasing complications the risks, benefits, and
rationale for ECT were discussed at length with the patient’s wife
and family. Given his history of responding positively to ECT in
the past for major depression with psychotic features, the family
agreed. The physician on the primary service concurred and the

psychiatrist specializing in ECT treatment agreed. Consideration
was given to obtaining a court order but further delay in treatment
was considered hazardous. Bilateral ECT treatment was initiated
and the patient demonstrated a dramatic functional improvement
after the first treatment. However, this response was not sustained.
Subsequent treatments ultimately resulted in marked and sustained
improvement to the point where the patient was able to begin eating,
sitting up at the bedside, ambulating and improvement ultimately
leading to discharge from the hospital. He was discharged home af-
ter receiving 6 total treatments with plans for additional outpatient
treatment.

At follow-up several months after his final ECT treatment he
denied any anxiety, depression or symptoms of psychosis. He had
fully returned to his baseline level of functioning with no residual
sequelae from his hospitalization or the treatments.

Discussion

Considering the patients recent intra-abdominal surgery, a
broad differential was considered including delirium secondary to
uremia, infections, metabolic derangements, or intestinal incarcer-
ation. However, he was afebrile and his medical workup was con-
sistently negative. His antirejection medications were considered as
a potential contributor to his condition. Tacrolimus has been noted
to cause psychosis and mycophenolate has been associated with in-
creased anxiety (14, 15). However, he had been on these medica-
tions since his transplant in 2016 and not experienced these adverse
effects.

Catatonia secondary to major depression with psychotic fea-
tures was the initial working diagnosis but discrepancies in his pre-
sentation brought put this in doubt. He also failed to respond to one
dose of 2 mg of IV lorazepam. Though a full lorazepam challenge
test involves a second dose if the patient does not respond, most
catatonic patients respond within 10 minutes; our patients lack of
response made catatonia a less likely diagnosis (16). Given the pa-
tient had absolutely no response to the first lorazepam dose, it was
decided not continue with a second. Benzodiazepines are consid-
ered to be the Gold standard for confirming a diagnosis of catatonia
as most cases will respond with a marked reduction of symptoms
within 10 minutes of a 2-4 mg IV lorazepam (17). A "lorazepam
test" cannot only confirm the diagnosis of catatonia but can also
bring the underlying psychopathology to light by enabling patients
to speak (18).

Conversion disorder, factitious disorder and malingering were
also considered but the latter two were ruled out. The patient had
been known to the department giving his recent surgery and treat-
ment at our hospital. He had never shown previous symptoms of
malingering or factitious disorder. His past psychiatric history was
also considered and made these diagnoses much less likely. The
clinical spectrum of conversion disorder is wide ranging. Accord-
ing to DSM 5, conversion disorder must have one or more symptoms
of altered voluntary motor or sensory function with clinical findings
that are incompatible with recognized neurological or medical con-
ditions (6). This patient not only met these criteria, but he also
experienced significant psychologic and physical stress as a result
of his surgical procedure, providing a plausible explanation for his
conversion symptoms. He had also expressed foreboding prior to
the procedure. Additionally, it is common for patients with conver-
sion disorder to suffer an underlying major depressive disorder. It
was not inconceivable that this was the case.

There have been a number of postoperative conversion disorder
cases reported in the literature (19-21). Furthermore, there have
been multiple documentations of conversion disorder presenting

22 translation@utoledo.edu Rapport et al.



with catatonia-like features similar to this patient’s (22, 23). The
treatment of the mute unresponsive patient requires a multidisci-
plinary approach with a combination of therapies. However, there
are scarce controlled studies of the treatment of such patients and
most information regarding the effectiveness of particular interven-
tions is anecdotal (24). Psychotherapy, either psychodynamic or
cognitive behavioral, continues to be the standard of care for con-
version disorder (3, 7). However, given the state of the patient, that
was not a plausible option. There are very few trials exploring the
use of pharmacotherapy, one study showing modest improvements
with SSRIs (9). Conversion disorder is not currently accepted as
an indication for the use of ECT. However, ECT has been demon-
strated in multiple cases to have been beneficial in patients with se-
vere conversion disorder (10-12). Other studies have shown a favor-
able response to ECT treatment for various somatoform disorders,
particularly cases with comorbid mood disorders (13). Although the
exact mechanism of ECT is unknown, its efficacy in treating mood
and thought disorders is well established (25). Major depression
with psychotic features can be a common underlying etiology of
both catatonia and conversion disorder and therefore may respond

to ECT, especially in an emergency.

Conclusion

ECT in the treatment of severe conversion disorder may be ap-
propriate and result in good clinical outcome. This is an example
and a reminder of how ECT may be a useful treatment in severe
conversion disorder when other options have failed.

Conflict of interest

Authors declare no conflict of interest.

Authors’ contributions

SS, RB, DR, JO wrote, edited manuscript and reviewed paper.
All authors read and approved the final document.

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