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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 36-38

An unusual case of functional neurological disorders and psychogenic coma following physical assault: Clinical and medico-legal considerations


1 Department of Legal and Forensic Medicine, University of Genova, Genova; Department of Legal and Forensic Medicine, Institute of Legal Medicine, Magna Græcia University of Catanzaro, Catanzaro, Italy
2 Department of Legal and Forensic Medicine, University of Genova, Genova, Italy
3 Department of Legal and Forensic Medicine, Institute of Legal Medicine, Magna Græcia University of Catanzaro, Catanzaro, Italy

Date of Submission30-Sep-2020
Date of Decision17-Dec-2020
Date of Acceptance01-Mar-2021
Date of Web Publication24-Mar-2021

Correspondence Address:
Rosario Barranco
Department of Legal Medicine, University of Genova, via De' Toni 12, 16132 Genova
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfsm.jfsm_62_20

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  Abstract 


Functional neurological disorders can have different clinical manifestations, including coma, in the setting of an unknown etiology. In this article, we present a case of a young man affected by intellectual disabilities who, after a physical assault reported serious neurological alterations and a functional coma. This case shows how a stressful psychophysical event can bring acute and variable neurological manifestations of functional significance to a victim with previous intellectual disabilities. Despite the growing interest in this field, research is still very limited and studies in this field could better explain the nature of the psychogenic coma. From a medico-legal point of view, problems of evaluation may emerge for these disorders emerge as a result of acute psycho-physical stress and without any detectable structural alterations.

Keywords: Functional coma, functional neurological disorder, psychogenic disorders, stressful events


How to cite this article:
Caputo F, Barranco R, Ricci P, Gratteri S, Frigiolini FM, Rocca G, Ventura F. An unusual case of functional neurological disorders and psychogenic coma following physical assault: Clinical and medico-legal considerations. J Forensic Sci Med 2021;7:36-8

How to cite this URL:
Caputo F, Barranco R, Ricci P, Gratteri S, Frigiolini FM, Rocca G, Ventura F. An unusual case of functional neurological disorders and psychogenic coma following physical assault: Clinical and medico-legal considerations. J Forensic Sci Med [serial online] 2021 [cited 2021 Jun 14];7:36-8. Available from: https://www.jfsmonline.com/text.asp?2021/7/1/36/311861




  Introduction Top


Functional disorders (which are also described as psychogenic or non-organic disorders) have been historically neglected in scientific research.[1] The diagnosis is based on the identification of clinical signs that are not compatible with an organic disorder.[2] In a minority of the cases, coma can be attributed to psychiatric causes.[3] Despite being a rare condition, psychogenic or functional coma represents a diagnostic dilemma.[4] In this work, the authors present the case of a 26-year-old man affected by intellectual disability who, after a physical assault, developed a series of neurological alterations and he fell into a functional coma.


  Case Report Top


A 26-year-old man suffering from mild-moderate intellectual disability was a victim of an assault perpetrated by several people. Anamnestic data revealed that the man had experienced head trauma after an accidental fall at the age of three, which induced generalized learning difficulties.

During the assault, that lasted about 15 min, he was punched and kicked in the head and was verbally assaulted. However, he did not lose consciousness at any given moment. After the assault, he immediately came back home accompanied by his friends. While he was returning home, his friends noticed that he began walking abnormally and had stopped talking. The next morning, he was brought to the hospital because he was in a soporous state with involuntary movements of his head, arms, and legs. By the time he arrived at the emergency room, his level of consciousness had improved but he appeared agitated. A brain computed tomography scan revealed there were no pathological findings. A cerebrospinal fluid analysis indicated there were no alterations and the toxicological tests were negative. In the meantime, the man began to suffer a generalized tonic-clonic seizure. He was sedated with propofol, fentanyl and midazolam, intubated, and administered intravenous therapy with levetiracetam. An electroencephalography (EEG) revealed an overall and generalized low voltage, which did not change even after the administration of flumazenil and naloxone. A brain magnetic resonance imaging ruled out any structural alterations. During the following days, the patient was awakened. A subsequent EEG revealed medium voltage slow activity with the predominance of theta-delta waves. On the 4th day of hospitalization, he presented tremors and paresis to the four limbs (which ceased with reassurance). On the 6th day of hospitalization, his EEG resulted normal during sleep and the pattern appeared organized and reactive during the wake stage. However, the patient presented signs of hostility, agitation, and motor restlessness. Due to the lack of organic alterations, the hypothesis of a possible psychogenic reaction to the trauma was considered. The patient remained disoriented as well as suffering from confabulation and amnesia during the remaining period of hospitalization. In the following days, the patient was tranquil, and his EEG results appeared normal. He was discharged on the 13th day after being diagnosed with a posttraumatic psychogenic reaction. Later on, the patient presented symptoms of posttraumatic stress disorder characterized by dissociative, anxiety, and sleep disorders. The cause of the functional neurological alterations was acute psycho-physical stress (derived from the assault).


  Discussion Top


Functional coma is an involuntary coma-like state that occurs in the absence of structural lesions or metabolic damage to the brain.[4] In the case here presented, neurological changes and the state of functional coma surfaced after the physical assault. A stressful stimulus can destabilize or desynchronize the components of the cognitive-emotional system and interfere with the activities of coordination and attention. This can result in aberrant behavioral, cognitive, and sensorimotor responses.[5] In addition, people with mental disabilities could develop abnormal neurocognitive disorders as adaptive behaviors in an attempt to control stressful events.[6],[7] In this case, the subject presented movement and consciousness disorders after the assault.

In the literature, two groups of patients with functional coma are recognized: those who become irresponsive due to explanations unrelated to surgery and those who become irresponsive after surgery.[8],[9] Furthermore, it is not clear if the use of anesthetic drugs may play a role in the underlying vulnerability.[10]

In this case, the patient's neurological picture was revealed to be highly complex as he entered into a state of coma that persisted despite the withdrawal of sedative drugs and the administration of antagonist drugs. A psychogenic nature was suspected days after when the patient awoke from the coma, and when the psychomotor alterations ceased when the patient was calm. From a medical-legal point of view, the absence of structural alterations of the brain caused problems in establishing a specific correlation with the physical assault.

A careful and casual link evaluation was performed through an in-depth Forensic evaluation[11] and Hill's causal criteria.[12] A temporal concordance throughout the causal chain was observed: in the case here presented, neurological changes and the functional coma occurred immediately after the physical assault.

The evaluation of cause-effect compatibility and congruity proved to be more difficult. Through a careful psychiatric and neurological examination, we investigated if the stressful event had a relevant psychological and emotional value for the victim, according to the vulnerable cognitive-emotional system. The assault was a stressful psychophysical event and the latter was worsened by the previous intellectual disabilities that the victim suffered from. However, a causal relationship between the assault and the functional coma is difficult to ascertain based on the results of a single case study. More consistent studies are needed in this field to verify correlations between violence and these types of neurological disorders.

Moreover, we excluded other causes of functional neurological disorders: In fact, the patient's condition was not justified by the presence of structural or metabolic damage and the psychomotor alterations tended to cease when the patient was calm. In our opinion, the stressful event was sufficient to determine a cause-effect relationship.

In conclusion, this case reveals how a stressful psychophysical event can determine the acute and variable neurological manifestations of functional significance in a subject with previous intellectual disabilities. The physical attack and neuropsychiatric consequences should be evaluated by the interdisciplinary collaboration of medicolegal experts in the field of neurology, psychiatry, and forensic medicine.

Research results are still very limited and further identification of cases along with a literary description could better explain the nature of the psychogenic coma.[4] From a medico-legal point of view, problems of evaluation may emerge if these disorders emerge as a result of acute psycho-physical stress without any detectable structural alterations. In particular, the causal correlation between a traumatic event such as a physical assault and the manifestation of the disorder cannot be evident, especially with subjects with preexisting neuropsychiatric diseases. Research in this area may be of interest to the forensic medical field for in some cases it is necessary to assess the responsibility of third parties when an onset of functional manifestations occurs.

On a final note, the aggressors who committed this crime were charged according to Italy's penal code.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Stone J, Carson A, Duncan R, Roberts R, Warlow C, Hibberd C, et al. Who is referred to neurology clinics? – The diagnoses made in 3781 new patients. Clin Neurol Neurosurg 2010;112:747-51.  Back to cited text no. 1
    
2.
Carson A, Hallett M, Stone J. Assessment of patients with functional neurologic disorders. Handb Clin Neurol 2016;139:169-88.  Back to cited text no. 2
    
3.
Zeman A. Plum and Posner's diagnosis of stupor and coma. J Neurol Neurosurg Psychiatry 2008;79:108-10.  Back to cited text no. 3
    
4.
Ryznar E, Wilcox D. Functional coma: Two case reports and a review of the literature. Psychosomatics 2019;60:343-51.  Back to cited text no. 4
    
5.
Baslet G. Psychogenic non-epileptic seizures: A model of their pathogenic mechanism. Seizure 2011;20:1-3.  Back to cited text no. 5
    
6.
Duncan R, Oto M. Psychogenic nonepileptic seizures in patients with learning disability: Comparison with patients with no learning disability. Epilepsy Behav 2008;12:183-6.  Back to cited text no. 6
    
7.
Van den Hout M, Arntz A, Merckelbach, H. Contributions of psychology to the understanding of psychiatric disorders. In: Gelder MG, Lopez-Ibor JL Jr., Andreasen NC, editors. New Oxford Textbook of Psychiatry. Oxford: Oxford University Press; 2000. p. 277-92.  Back to cited text no. 7
    
8.
Meyers TJ, Jafek BW, Meyers AD. Recurrent psychogenic coma following tracheal stenosis repair. Arch Otolaryngol Head Neck Surg 1999;125:1267-9.  Back to cited text no. 8
    
9.
Leners JC. Case report: Psychogenic coma experienced by a psychotic patient. Bull Soc Sci Med Grand Duche Luxemb 2002;(1):23-5.  Back to cited text no. 9
    
10.
Downs JW, Young PE, Durning SJ. Psychogenic coma following upper endoscopy: A case report and review of the literature. Mil Med 2008;173:509-12.  Back to cited text no. 10
    
11.
Magalhães T, Vieira DN. Personal injury assessment. In: Madea B. Handbook of Forensic Medicine. Bonn: Wiley; 2014. p. 1241-52.  Back to cited text no. 11
    
12.
Morabia A. On the origin of Hill's causal criteria. Epidemiology 1991;2:367-9.  Back to cited text no. 12
    




 

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