Psychogenic Coma following Upper Endoscopy: A Case Report and Review of the Literature

Abstract

We reviewed the literature and identified 10 previously reported cases of postanesthesia psychogenic coma. We have compared and contrasted our case with the 10 previous reports and propose bedside clues to assist the physician with diagnosing this unusual condition.

Repeated episodes of difficulty with arousal following general anesthesia in a patient with ulnar neuropathy

“…Regardless, delayed emergence in a patient who previously experienced "functional" delayed awakening should alert the anesthesiologist to the possibility of a psychiatric cause. Indeed, in the majority of previously reported cases, the patient had a signifi cant psychiatric history, including primary psychiatric disorders (depression, bipolar disorder, posttraumatic stress disorder, anxiety, or substance abuse history) [4,[6][7][8]11,14] and/or personality disorder (borderline and histrionic personality traits) [3,4]. Our patient had undergone preoperative psychiatric evaluation which did not reveal either a psychiatric or a personality disorder.…”

“…Repeat episodes of psychogenic delayed awakening have been reported in four patients. [3,4,7,12] Our patient differed in that she experienced episodes of uneventful emergence from general anesthesia that alternated with episodes of delayed awakening. Review of her medical record could not identify an obvious organic mechanism to explain the delayed awakening.…”

“…Psychogenic coma following general anesthesia is rare [3,4,[6][7][8][10][11][12][13][14][15]. Most previous cases involved female patients undergoing otolaryngologic or gynecologic procedures.…”

“…Because psychogenic coma is a diagnosis of exclusion, patients undergo an extensive work-up to identify potentially lifethreatening conditions. These patients usually have an underlying psychiatric or psychological condition, personality disorder, or external incentive for symptom fabrication [3,4,[6][7][8]10,11]. We report a unique case of a woman with no history of psychiatric disorders or were dilated, responsive to light, and 7 mm in diameter.…”

“…However, there are rare situations in which delayed emergence from anesthesia may be the result of psychogenic factors ("psychogenic coma"); namely, factitious, conversion, and dissociative disorders [3][4][5][6][7][8][9]. Because psychogenic coma is a diagnosis of exclusion, patients undergo an extensive work-up to identify potentially lifethreatening conditions.…”