The Daily Differential — Monday, July 6, 2026

Conversion Disorder

This diagnosis is common, easy to mishandle, and often triggered by a high-stakes neurologic mimic. Missing an organic cause harms patients; mishandling the conversation can lock in disability and repeat ED use.

By the Blue Fish Med Desk Jul 6, 2026 · Phoenix

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A 29-year-old woman in scrubs sits on the ED stretcher with tear tracks drying on her cheeks, her left leg hanging limp while her right foot taps the bedrail. Her vitals are calm, her skin is warm, and her speech is halting but clear; she says the weakness “just came on” after a fight at work. She can’t explain why the leg won’t move, yet when someone drops a blanket, she flinches before she thinks about it. The chart already says “stroke rule-out,” but the bedside picture is not lining up — and the next move matters.

— What’s your move? Read on.

Before you read

What dangerous diagnoses still must be excluded before you make the call?
How do you avoid telling the patient “it’s just stress” while still giving a useful ED plan?

When to Think of It

Think of conversion disorder when neurologic symptoms are inconsistent, internally incongruent, or clearly nonanatomic: abrupt weakness with give-way strength, tremor that changes with distraction, non-epileptic shaking with preserved awareness, or sensory loss that does not map to a neuroanatomic pattern. It often follows stress, trauma, pain, or a psychiatric trigger — but the diagnosis is made by positive exam features, not by “nothing found.”

Sick or Not Sick

The single fork is: does this patient still need a workup for an acute neurologic, toxic, metabolic, or infectious emergency? If the answer is yes, continue the medical evaluation; if no and the exam is convincingly functional, shift to supportive diagnosis and disposition.

The First Fifteen Minutes

If stroke is possible (sudden focal deficit, aphasia, visual field cut, facial droop, persistent objective asymmetry) → activate stroke pathway immediately; manage per protocol, because functional symptoms do not protect against real stroke.
If seizure is ongoing or there is concern for status epilepticus (altered mental status, cyanosis, rhythmic activity, tongue biting, urinary incontinence, persistent postictal state) → lorazepam 2–4 mg IV (or midazolam 10 mg IM if no IV), because benzodiazepines stop true convulsions.
If hypoglycemia is present or not yet excluded → dextrose 25 g IV (e.g., D50W 50 mL IV) because glucose derangement can mimic focal neurologic disease.
If opioid or sedative intoxication is possible → targeted reversal only when indicated: naloxone 0.04–0.4 mg IV/IM/IN, titrate to ventilation, because overshooting can precipitate withdrawal; flumazenil is generally avoided except in rare, expert-guided cases.
If the exam is convincingly functional and life threats are excluded → provide calm reassurance, avoid repeated painful testing, give a clear explanation of symptoms as real and reversible, and engage social work / psychiatry when available, because validation reduces escalation.

Definitive Care & Disposition

There is no ED “cure.” The best care is a confident, nonjudgmental explanation, documentation of positive functional signs, and arrangement for outpatient neurology, psychiatry, or behavioral health follow-up. Admit only if there is another medical reason, unsafe ambulation, inability to care for self, or unresolved diagnostic uncertainty.

How This One Kills

The classic failure is anchoring on “psych” and missing a true stroke, seizure, spinal cord lesion, toxic ingestion, or hypoglycemia. The opposite miss is overtesting a clearly functional presentation and reinforcing illness behavior.

The Differential — What Else Looks Like This

Acute ischemic stroke — objective vascular-pattern deficit, and confusing the two risks thrombolysis delay or missed reperfusion.
Focal seizure with postictal weakness — transient deficit after a witnessed event, and confusing it with conversion can miss epilepsy.
Spinal cord compression — back pain, sensory level, urinary symptoms, and confusing it with conversion can miss a time-sensitive neurosurgical emergency.
Hypoglycemia — autonomic symptoms or altered mentation with rapid glucose response, and confusing it with conversion can be fatal.

The Second-Day Story

In older adults, conversion-like symptoms are less common and a new focal deficit should be treated as organic until proven otherwise. In younger patients, the presentation may be dramatic but inconsistent, with symptoms that worsen when observed and improve with distraction. Some patients present with mixed functional and organic disease, so the presence of functional signs does not end the medical evaluation if anything in the story is off.

Back to Our Patient

Back to our 29-year-old woman in scrubs with sudden left leg weakness after an argument: she has give-way weakness, a positive Hoover sign, normal speech, no facial droop, normal glucose, and no headache, trauma, back pain, or sensory level. She is recognized as having a functional neurologic presentation only after stroke, seizure, and metabolic red flags are assessed and are not present; she is risk stratified as not sick from an ED-neurologic standpoint. In the first fifteen minutes, we avoid unnecessary escalation, explain that the symptoms are real and commonly triggered by stress but not under voluntary control, and arrange safe follow-up. She is discharged with return precautions for new objective neurologic symptoms and outpatient neurology/behavioral health referral.

Patient Presentation to Attending

How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling

“29-year-old woman with acute left leg weakness that started after an argument at work. She has no headache, trauma, back pain, speech change, facial droop, sensory level, or loss of consciousness, and her glucose is normal. On exam she has give-way weakness and a positive Hoover sign; her cranial nerves and mental status are intact, and the deficit is inconsistent with a vascular pattern. I’m concerned for a functional neurologic symptom disorder after excluding stroke and other emergent mimics. I’m not giving sedatives or more invasive testing right now; I’d like to document the positive exam findings, provide a nonjudgmental explanation, and arrange outpatient follow-up with strict return precautions.”

Study Directive

Practice identifying 3 positive functional exam signs from memory: Hoover sign, give-way weakness, distractible tremor.
Write a 30-second script for explaining functional neurologic symptoms without using “it’s all in your head.”
Review one stroke mimic case and list the red flags that should override a functional impression.
Build a one-page differential for acute unilateral weakness that includes stroke, seizure, hypoglycemia, spinal cord lesion, and conversion disorder.

Recent Literature

Review or guideline Diagnosis and management of functional neurological disorder
Aybek S, Perez DL · BMJ, 2022 · PMID 35074803 · cited 278×

A practical reference for ED-relevant FND/conversion disorder care: make a positive bedside diagnosis using internal inconsistency and rule-in signs, screen for neurologic emergencies, communicate the diagnosis nonjudgmentally, and arrange

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Eating Disorders

Eating disorders kill through arrhythmia, electrolyte collapse, organ dysfunction, and suicide. The ED job is to spot physiologic instability early and...

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The Case

A 17-year-old girl in a hoodie keeps tugging her sleeves over her hands while her mother answers most of the questions. The ECG monitor flickers with a slow rate, and her cheeks are sunken enough that the shadows look carved in. She says she’s “fine,” but she won’t stand up without getting lightheaded, and the bathroom smell from home is suddenly easy to imagine. Nobody has said the words out loud yet, but the body is already telling the story.

Before You Read

What findings make an eating disorder medically dangerous today?
Which electrolyte and cardiac complications should you check before letting the patient leave?
What makes this a psychiatric admission, a medical admission, or both?

Why It Matters

Eating disorders kill through arrhythmia, electrolyte collapse, organ dysfunction, and suicide. The ED job is to spot physiologic instability early and prevent a catastrophic discharge.

When to Think of It

Suspect an eating disorder in adolescents and young adults with weight loss, restriction, binge/purge behavior, excessive exercise, bradycardia, orthostasis, amenorrhea, parotid swelling, dental erosion, calluses on knuckles, dehydration, or repeated vague GI complaints. Bulimia may look “normal weight” while still carrying dangerous electrolyte and arrhythmia risk.

Sick or Not Sick

The single call is: is the patient medically unstable from malnutrition or purging? Red flags include bradycardia, hypotension, orthostasis, syncope, hypothermia, QT prolongation, severe electrolyte abnormalities, dehydration, arrhythmia, or inability to safely eat/drink. If unstable, they need medical admission, often with psychiatric co-management.

The First Fifteen Minutes

Check glucose immediately if altered, weak, or syncopal → dextrose 25 g IV if hypoglycemic, because malnutrition can precipitate low glucose.
Obtain ECG and telemetry if bradycardic, purging, weak, syncope, or electrolyte concern, because QT prolongation and bradyarrhythmia can precede sudden death.
Replace electrolytes when low:
Potassium chloride PO/IV per severity and access, commonly 10–20 mEq IV per hour via peripheral line, or higher via central access per protocol; check institutional limits.
Magnesium sulfate 2 g IV for hypomagnesemia or QT prolongation, because magnesium stabilizes myocardium and helps correct refractory hypokalemia.
Phosphate replacement if low, with dosing per severity and route; check local protocol because formulations vary.
If severe agitation, delirium, or seizure occurs from metabolic derangement → treat the underlying abnormality first; benzodiazepines do not fix the cause.
If vomiting or dehydration is significant → 0.9% normal saline IV bolus 1–2 L in adults as needed, because volume repletion improves perfusion and orthostasis.
If concern for thiamine deficiency, especially with prolonged poor intake or concurrent alcohol use → thiamine 100 mg IV before significant glucose-containing fluids when feasible, because it helps prevent Wernicke encephalopathy.

Definitive Care & Disposition

Medical admission is indicated for physiologic instability, severe electrolyte derangement, QT prolongation, syncope, ongoing purging with arrhythmia risk, or inability to maintain oral intake. Psychiatry, adolescent medicine, nutrition, and social work should be involved early; definitive treatment is multidisciplinary and longitudinal, not ED-based. Discharge only when medically stable, safe follow-up exists, and the patient can reliably eat/drink.

How This One Kills

The classic failure is focusing on weight alone and missing the unstable “normal-weight” purging patient with a dangerous potassium or magnesium deficit. The other miss is discharging a bradycardic, orthostatic adolescent because the family promises follow-up.

The Atypical Presentation

Men, older adults, athletes, and patients with higher body weight can still have clinically significant restrictive or purging eating disorders. Some present not with explicit body-image complaints but with syncope, palpitations, constipation, stress fractures, or repeated “electrolyte” visits. Adolescents may minimize symptoms, while parents may describe ritualized meals, bathroom trips, or hidden exercise.

Back to Our Patient

Back to our 17-year-old in the hoodie with bradycardia and orthostasis: the combination of restrictive intake, lightheadedness, sunken appearance, and likely purging behavior makes an eating disorder medically dangerous until proven otherwise. She is recognized by the malnutrition/purging phenotype, and she is risk stratified as unstable because the slow pulse and orthostatic symptoms could precede arrhythmia or collapse. In the first fifteen minutes, we check glucose, ECG, potassium, magnesium, phosphate, and hydration status, give thiamine if indicated, and correct abnormalities while placing her on telemetry. She needs medical admission with psychiatric and nutrition consultation rather than discharge.

Patient Presentation to Attending

“17-year-old female with restriction and possible purging who presents with lightheadedness and bradycardia. She looks malnourished, has orthostatic symptoms, and her family reports reduced intake and frequent bathroom trips after meals. I’m worried about an eating disorder with medical instability rather than simple dehydration, and I’ve already ordered ECG, glucose, electrolytes including magnesium and phosphate, and placed her on telemetry. My plan is admission for monitoring and repletion, with psychiatry and nutrition involved early.”

Study Directive

Memorize the ED instability criteria for eating disorders and recite them without notes.
Practice reading 3 ECGs: sinus bradycardia, prolonged QT, and U waves from hypokalemia.
Make a repletion plan for potassium, magnesium, and phosphate using your department’s protocol.
Learn a 30-second nonjudgmental script for discussing restriction/purging with adolescents and families.

Key Medications

Dextrose 25 g IV for hypoglycemia.
0.9% normal saline 1–2 L IV bolus for dehydration/orthostasis, titrated to response.
Magnesium sulfate 2 g IV for hypomagnesemia/QT prolongation; may repeat depending on level and renal function.
Potassium chloride: commonly 10 mEq IV per hour peripheral, sometimes 20 mEq IV per hour central with monitoring; verify with protocol.
Thiamine 100 mg IV before glucose-containing fluids when deficiency risk exists.
Phosphate replacement: dosing varies by severity and formulation; check institutional guidance.

High-Yield Pearls

BMI is not a safety check; electrolytes and ECG are.
Normal serum phosphorus can fall rapidly after refeeding, so “initially okay” does not mean safe.
Repeated “GI complaints” plus dental erosion or parotid swelling should trigger a purging history.

The Mimics

Inflammatory bowel disease — GI symptoms and weight loss with inflammatory markers, and confusing the two can delay psychiatric and nutritional treatment.
Hyperthyroidism — weight loss with tachycardia and heat intolerance, and confusing it with anorexia misses endocrine disease.
Depression — poor intake and weight loss, but eating-disorder cognitions and purging behaviors are the discriminators.
Malignancy — weight loss and fatigue, and confusing it with eating disorder can miss cancer; red flags are fevers, night sweats, focal findings, or progressive pain.

Board Question

A 19-year-old woman with presumed bulimia presents with weakness and palpitations. She has a normal BMI, but ECG shows QT prolongation and labs reveal hypokalemia. What is the most appropriate next step?

AReassure her because normal weight excludes medical risk
BDischarge if she can tolerate oral intake
CAdmit for telemetry and electrolyte correction
DStart benzodiazepines for anxiety

Reveal answer

Correct: C

Purging patients can have life-threatening electrolyte disturbances despite a normal BMI. QT prolongation and hypokalemia require monitored correction because of sudden arrhythmia risk.

Recent Literature

Review or guideline Eating Disorders
Emerg Med Clin North Am, 2024 · cited 4×

EM-focused review covering recognition, medical instability, electrolyte/QT complications, refeeding risk, and disposition thresholds for patients with anorexia, bulimia, and related eating disorders.

TheDaily Differential

Conversion Disorder

When to Think of It

Sick or Not Sick

The First Fifteen Minutes

Definitive Care & Disposition

How This One Kills

The Second-Day Story

Study Directive

Recent Literature

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Eating Disorders

Refeeding Syndrome

Alcohol Dependence and Abuse

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