A 61-year-old Japanese woman lost consciousness at her office and recovered a few minutes later. Eight days after this episode, she was admitted to a hospital due to the appearance of diverse and fluctuating symptoms, such as sub-stupor, disorganized behavior, and paranoia. She had no relevant medical history. She was the youngest of four siblings. She received average grades in her school days, and she liked sports. She got a job after graduating from high school. Although she got this job, she retired relatively early because of poor social relationships. She got married at the age of 22. She gave birth to and raised three children, to whom she was a good mother. Two years before the current episode, her husband died; consequently, she lived alone. However, her daughter and son lived nearby.
Her physical examination; findings of blood tests, non-contrast-enhanced head computed tomography (CT), and magnetic resonance imaging (MRI) were unremarkable and did not suggest a cause for the symptoms; thus, she was transferred to our hospital for better diagnosis and management. She often laid in her bed with her eyes open and had occasional outbursts of paranoia in which she would ask: "Are you going to kill me?" Because these symptoms were acute at the onset and neither she nor her family had a history of psychiatric illness, we suspected an organic neurological disorder, such as encephalitis. Various tests were conducted to confirm our diagnosis. Indeed, we found intermittent generalized slow-wave activity on electroencephalography (EEG), elevated serum CA19-9 levels (118.3 IU/mL, normal range: < 35 IU/mL), and slightly elevated immunoglobulin G levels (5.8 mg/dL, normal range: < 4.3 mg/dL) in the cerebrospinal fluid. CT and MRI scans were normal.
We administered 400 mg of valproic acid (blood concentration: 65.2 mug/mL) on the 17th day for suspected epilepsy. This was followed by steroid pulse therapy on the 22nd day for suspected autoimmune disease, including paraneoplastic neurological syndrome; however, these treatment options had no effect. No autoantibodies were found, eliminating the possibility of an autoimmune disease. On the 29th day, a carcinoma of the tail of the pancreas was observed on contrast-enhanced CT, and a surgery was scheduled. Although she did not receive treatment that targeted the psychiatric symptoms directly, they improved spontaneously and gradually. A few days before the surgery, the psychiatric symptoms were almost fully recovered (around the 60th day). The pancreatic tumor resection was performed on the 67th day, and her postoperative stay was uneventful. The psychiatric symptoms disappeared, and she was discharged on the 92nd day under a continuous treatment with 400 mg of valproic acid. The cause of the psychiatric symptoms could not be identified.
Following discharge, she led an active life at her daughter's house without any issues or new psychiatric events. On the 110th day, the gastroenterologist explained to her that she had a life expectancy of <2 years based on the intraoperative pathological findings. The next day, she presented with stupor again:in the form of a similar episode as that during the first admission:and she was readmitted to our hospital.
On second admission, head CT and single-photon emission computed tomography (SPECT) scans were performed, but no abnormalities were found. Based on the previous clinical presentation and this one, together with the clear psychological stress, normal physical examination, and absence of abnormal imaging (head CT and MRI, SPECT, and EEG) and laboratory workup findings, a diagnosis of dissociative stupor was made. Furthermore, a relative mentioned that she had stupor for several weeks at the age of 32 when her husband turned down her religious invitation, which improved spontaneously without any medical management. We found out later that her religious beliefs meant that she was against medical treatment. Her hospitalization led to thorough medical help, which may have contributed to the relapse and prolongation of the stupor. To relieve her anxiety, we remained considerate of her feelings; however, the stupor persisted, which made the psychological management challenging. Since valproic acid was ineffective in preventing stupor, we stopped valproic acid administration and initiated treatment with 3 mg of lorazepam to relieve her nervousness on the 116th day. Her symptoms partially improved following this treatment, and we observed her playing table tennis. However, soon afterward, she fell into a stupor again. Eventually, she could not eat at all, and oral treatment was interrupted. Since her condition could not be stabilized and lorazepam alone was insufficient to relieve her anxiety and nervousness, we administered 3 mg of lorazepam again via a nasogastric tube. On the 149th day, we initiated 10 mg of escitalopram to reduce her anxiety. After a week, we increased the dose of escitalopram to 20 mg. At this point, her symptoms partially improved, and she talked more frequently, but she still fell repeatedly and suddenly into a stupor. Since treatment with escitalopram partially improved her stupor, we speculated that medication acting on the serotonergic system would be a more effective treatment. The psychiatric symptoms disappeared a few days after adding 3 mg of aripiprazole to her treatment. She was released from the hospital seven months after the initial hospitalization. We may have refrained from pursuing the inducement in detail, considering her short life expectancy. However, even after the psychiatric symptoms disappeared completely, she had no memory of the situation just before and in the middle of the stupor. The presence of amnesia also supported the diagnosis of dissociative stupor. Despite the antitumoral treatment and palliative care for cancer recurrence, her psychiatric state remained stable until her death from pancreatic cancer a year and 3 months after discharge (Figure 1).