A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 35-year-old woman is brought to the emergency department by her coworkers after a sudden onset of vision loss. She is a lawyer and lost 3 cases in the past week. Yesterday, she experienced weakness and paralysis of her left wrist. Past medical history is significant for acid reflux. Physical examination reveals 2/4 in reflexes and 5/5 in muscular strength in all extremities. She appears indifferent to her current situation and presents with a flat affect. Slurring of words is absent. CT without contrast and MRI of the brain are unremarkable. Which of the following is the most likely diagnosis?
-
A
Factitious disorderIncorrect. Factitious disorder involves CONSCIOUS feigning for the sick role; conversion symptoms are unconsciously produced.
-
B
Transient ischemic attackIncorrect. TIA would follow a vascular distribution and typically resolve within 24 hours; multifocal incoherent symptoms with normal imaging argue against it.
-
C
Major depressive disorderIncorrect. MDD requires sustained mood/anhedonia; her flat affect here reflects 'la belle indifférence,' not depression.
-
D
Conversion disorderCorrect. Conversion disorder: neurological symptoms incompatible with anatomy, normal workup, often follows acute psychological stress; 'la belle indifférence' is a classic clue.
-
E
MalingeringIncorrect. Malingering involves intentional symptom production for an obvious external secondary gain (e.g., money, avoiding work); this patient's symptoms are unconsciously produced after acute psychological stress, consistent with conversion disorder.
↑ Tap an answer to reveal the reasoning
Answer: D. A young woman with sudden onset of vision loss and prior episode of wrist paralysis after major life stressors (losing 3 cases) has a NEUROLOGIC deficit that is anatomically incoherent (changing in pattern, with preserved 5/5 strength and 2/4 reflexes, normal neuroimaging) and accompanied by 'la belle indifférence'—a flat, indifferent affect inconsistent with the apparent severity. This is CONVERSION DISORDER (functional neurological symptom disorder, DSM-5)—neurological symptoms (motor or sensory) without an organic explanation, typically triggered by psychological stress, NOT consciously feigned.
Key discriminators from other diagnoses:
- FACTITIOUS DISORDER: intentionally feigning illness for the internal psychological reward of the sick role (no external gain). Inconsistent here because conversion symptoms are UNCONSCIOUS; the patient genuinely experiences them.
- MALINGERING: feigning illness for clear external gain (money, avoiding work, drugs).
- MAJOR DEPRESSIVE DISORDER: requires persistent mood symptoms, anhedonia—not present.
- TRANSIENT ISCHEMIC ATTACK: vascular distribution, sudden onset and resolution within 24 hours; the multifocal anatomically-incoherent symptoms here don't fit a vascular pattern, and imaging is unremarkable.
La belle indifférence (inappropriate calm about a serious symptom) is a classic but not sensitive or specific feature of conversion disorder. Treatment is psychoeducation, CBT, and physical therapy.
**Why each option:**
**A.** Factitious disorder involves CONSCIOUS feigning for the sick role; conversion symptoms are unconsciously produced.
**B.** TIA would follow a vascular distribution and typically resolve within 24 hours; multifocal incoherent symptoms with normal imaging argue against it.
**C.** MDD requires sustained mood/anhedonia; her flat affect here reflects 'la belle indifférence,' not depression.
**D.** Correct. Conversion disorder: neurological symptoms incompatible with anatomy, normal workup, often follows acute psychological stress; 'la belle indifférence' is a classic clue.