Health Questions and Answers

Question: I think my patient is faking it. How can I tell if this is psychogenic coma?

Answer:

First, be grateful. A patient in psychogenic coma is better than one who is angry and combative. Approach the patient incorrectly, and you can awaken the patient to a hostile alert state. Do a careful neurologic examination. Open the eyelids. If the eyes deviate upward and only the sclera show (Bell’s phenomenon), you should suspect psychogenic coma. When the eyelids are opened in a patient with true coma, the lids close slowly and incompletely. It is difficult to fake this movement. Lift the arm and drop it toward the face; if the face is avoided, this is most likely psychogenic coma. If this does not work, you may want to check some simple laboratory tests, including a Dextrostix. If the patient remains comatose, irritating but nonpainful stimuli, such as tickling the feel with a cotton swab, may elicit a response. Remember that this test is not a test of wills between you and the patient. There is no indication for repeated painful stimulation because it can make the patient angry and ruin attempts at therapeutic intervention.

If all else fails, perform cold caloric testing. The presence of nystagmus confirms the diagnosis of psychogenic coma.

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