Guwahati, Assam: When Chandni (name changed), a 26-year-old from Guwahati, suddenly lost her ability to speak, her family rushed her to the nearest government tertiary care centre. Despite being able to understand others, Chandni couldn’t open her mouth or form sounds. This sudden and unexplained loss of speech was incredibly distressing for her.
Medically, Chandni’s symptoms were indicative of Broca’s aphasia—a neurological condition often signalling a stroke. Ideally, an MRI scan should have been performed promptly, leading to a diagnosis of stroke and subsequent thrombolysis (a procedure to remove a thrombus using clot-busting medication). However, like many women in India, Chandni’s condition was dismissed as a mental illness.
Admitted to the psychiatric ward, she received only intravenous fluids and vitamin injections. It wasn’t until she lost movement in one side of her body that a stroke was considered and an MRI was finally done. By then, Chandni had lost both her speech and movement in her right upper and lower limbs—damage that could have been avoided with timely and proper medical intervention.
Overdiagnosis of conversion disorder
In India, as in Western countries, the diagnosis of conversion disorder—a psychiatric condition where the patient is thought to fake neurological symptoms—is frequently overdiagnosed, particularly in women. One of the earliest lessons my father, a senior physician, taught me was to suspect women of faking neurological symptoms. It took me a long time to unlearn this harmful bias. Throughout my practice, I have repeatedly heard this sentiment echoed by many healthcare professionals, who not only believe it themselves but also make it a point to teach it to their juniors.
Unlearning bias through experience
The reason I had to and could unlearn it was that when one focused on evaluating these complaints in women, eventually a medical cause almost always came up. I recall a 60-year-old woman with diabetes who couldn’t stop vomiting and was regularly accused by various healthcare providers of faking it. When she was admitted to CMC Vellore for further evaluation, most of her initial tests were normal. But we eventually performed a gastric motility test, discovering that her stomach nerves were so damaged that her stomach couldn’t move food – a condition known as gastroparesis, common in diabetics. This led to her regurgitating what she ate regularly. Appropriate medication and dietary adjustments led to immediate improvement of her condition. There are innumerable examples of similar cases from my practice which made me challenge the bias which was force-fed to me by older healthcare professionals.
Psychiatric conditions – a diagnosis of exclusion
In theory, psychiatric conditions as a cause of bodily symptoms are a diagnosis of exclusion, meaning that one should consider a psychiatric cause only after all other biological causes of disease are ruled out. However, many doctors find it easier to diagnose hysteria or conversion disorder, especially in women, without thorough evaluation. This trend is not just prevalent in India but is a global issue, reflecting a deep-seated gender bias in medical diagnosis.
Even overt psychiatric symptoms can have physical causes. For instance, severe depression can be a symptom of hypothyroidism, and anaemia can cause heart palpitations that might be mistaken for anxiety. Psychiatric symptoms in women might also suggest limbic encephalitis, an inflammation of the limbic system – the centre of the brain dealing with emotion, which is often autoimmune. A news article from TOI showed that a woman experiencing hallucinations and being treated by a psychiatrist was eventually diagnosed to have a brain tumour. These examples show that it is important to consider all possible medical explanations before jumping to conclusions that a person is having a psychiatric illness.
The urgent need for systemic reform
In developed countries, patient advocacy groups as well as individuals are taking it upon themselves to ensure that concerns of patients are not being invalidated or misdiagnosed. While it is very common in those countries for women to demand further evaluation, seek second opinions and advocate for themselves, this is very uncommon in India. Because of social and economic marginalisation, many women in India are treated as financial liabilities when they fall sick by their own families and find it difficult to access quality care in the face of such rampant bias.
Reform at the level of the healthcare system is thus crucial to ensure that these women do not remain underserved. Medical training should include modules on gender bias and its impact on diagnosis and treatment. Future healthcare professionals should be taught to approach each case with an open mind, free from preconceived notions about gender. This education should also stress the importance of empathy and patient-centred care, ensuring that all patients, regardless of gender, are treated with dignity and respect.
Moreover, healthcare systems must implement protocols and guidelines to prevent the premature diagnosis of psychiatric disorders without thorough investigation. This includes promoting interdisciplinary collaboration where neurologists, psychiatrists, and other specialists work together to evaluate complex cases. Such collaboration can lead to more accurate diagnoses and better patient care.
Empowering patients
Patients should be empowered to advocate for themselves within the healthcare system. They should be informed of their right to second opinions and encouraged to seek further evaluation if they feel their concerns are not being adequately addressed. Patient advocacy groups and public health campaigns can play a vital role in raising awareness about these issues and supporting those affected.
Doing my part
I recently had the opportunity to admit a patient who had symptoms of muscle stiffness and generalized tiredness to my hospital. She had been refused admission elsewhere after being told that her condition appears psychiatric. A junior doctor working with me on the case asked if I thought it was conversion disorder. I explained to her that this diagnosis should only be considered as a last resort. Together, we conducted a thorough neurological examination and blood tests, diagnosing her muscle rigidity as a heat-related illness. The patient got better after treatment After we discharged this patient, we also discussed how patients with genuine conversion disorder often have a history of sexual abuse and the importance of considering such histories in inpatient evaluations. I hope the junior doctor remembers this through the rest of her career and teaches it to her juniors too.
(Photo Courtesy: Cover Representative Image from Canva.)
