The patient is unresponsive and brought to the emergency
department on a stretcher. There is usually a history of recent emotional
upset--an unexpected death in the family, or breakup of a close relationship.
The patient may be lying still on the stretcher or demonstrating bizarre
posturing or even seizure-like activity. The patient's general color and vital
signs are normal, without any evidence of airway obstruction. Commonly, the
patient will be fluttering his eyelids or will resist having his eyes opened.
A striking finding is that the patient may hold his breath when the examiner
breaks an ammonia capsule over the patient's mouth and nose (real coma victims
usually move the head or do nothing). A classic finding is that when the
patient's apparently flaccid arm is released over his face, it does not fall
on the face, but drops off to the side. The patient may show remarkably little
response to painful stimuli, but there should be no true focal neurologic
findings and the remainder of the physical exam should be normal.
What to do:
Do a complete physical exam. Patients sometimes react with hysterical coma
under stress of illness or injury.
When there is significant emotional stress involved, administer a mild
tranquilizing agent such as hydroxyzine pamoate (Vistaril) 50-l00mg im.
Do not allow any visitors and place the patient in a quiet observation
area, minimizing any stimulation until he "awakens." Check vital signs every
o If there is a question of a generalized seizure, verify with a lactate level
or blood gas that shows metabolic acidosis.
When the patient becomes more responsive, re-examine him, obtain a more
complete history, and offer him followup care, including psychological support
If the patient is not awake, alert, and oriented after about 90 minutes,
begin a more comprehensive medical workup.
What not to do:
Do not get angry with the patient and torture him with painful stimuli in
an attempt to make him "wake up."
Do not perform an expensive workup routinely.
Do not ignore or release the patient who has not fully recovered. Instead,
he must be fully evaluated for an underlying medical problem, which may
require hospital admission.
True hysterical coma is substantially an unconscious act
that the patient cannot control. Antagonizing the patient often prolongs the
condition, while ignoring him seems to take the spotlight off his peculiar
behavior, allowing him to recover. Some psychomotor or complex partial
seizures are difficult to diagnose with their dazed confusion or fuge-like
activity, and might be labeled hysterical. If the diagnosis is not obviously
hysteria, the patient might need an EEG during sleep and deserves a referral
to a neurologist.