An eight-year-old girl was referred to the Institute of Maternal and Child Health, Calicut with a diagnosis of "Rabies". On admission, she showed the characteristic signs of aerophobia and hydrophobia. Fanning a current of air over the face or switching on the fan could elicit the characteristic fear reaction. She could not swallow water and bringing water close to the mouth elicited abnormal spasms of the face and muscles of deglutition. The features of aerophobia and hydrophobia were consistent. She also showed bizarre movements involving all four limbs. Except for the aerophobia, hydrophobia and bizarre movements, the nervous system examination was normal.

There was history of being bitten by a cat one month back and the cat died, few days after the incident.

A provisional diagnosis of rabies was made and the girl was given supportive treatment. Two days later, she improved dramatically and the symptoms disappeared completely. A child psychiatric evaluation revealed the following facts. She belonged to a lower socio-economic class family, consisting of her parents and two brothers. Her developmental mile-stones were normal. Her maternal aunt had some chronic psychiatric illness. There used to be frequent quarrels between the siblings and she had the feeling that her parents gave more attention to the brothers. She had normal intelligence. Her academic functioning was above average. She was well adjusted at school. The girl had a sensitive temperament. On the particular day she had a quarrel with her younger brother at school. She was insulted by him when she developed fainting episode. While friends and teachers were attending to her, the brother expressed aloud, that he was not bothered even if his sister died. This precipitated the bizarre movements.

Corneal impression smears for rabies antigen and serological tests for antirabies antibodies (done from Pasteur Institute, Coonore) were negative. So a retrospective diagnosis of conversion disorder was made.

Conversion disorders are closely associated, in time, with traumatic events, or disturbed relationships. The term conversion implies that the unpleasant affect caused by the conflicts that the individual cannot solve is transformed into the symptoms(1). Several studies have documented a close association between psychosocial stress and conversion disorder and sibling rivalry is reported to be one of the factors involved(2,3).

Pseudorabies or pseudohydrophobia, where the person after an animal bite behaves as if he is afflicted with rabies, is well documented in literature and is one of the most important differential diagnoses of rabies(4). The psychodynamics of the present case is different. Here the child had a painful experience, which was traumatizing to her ego, and this precipitated the conversion symptoms. Development of the symptoms helped to reduce the psychological distress and anxiety resulting from the conflict (primary gain). It also helped to gain more attention from the parents and teachers and classmates (secondary gain). Abrupt onset of the symptoms, association with stress, dramatic recovery and the presence of primary and secondary gains are all characteristic features of conversion disorder.

Anand M.R.,
Krishnakumar P.,
Medical College,
Calicut, Kerala.
Correspondence to:
Dr. P. Krishnakumar,
Senior Lecturer In Pediatrics,
E-mail: [email protected]

1. World Health Organization. ICD-10 Classification of mental and behavioral disorders. Oxford University Press, 1992: F4: 151-161.

2. Malhi P and Singhi P. Clinical Characteristics and outcome of children and adolescents with conversion disorder. Indian Pediatr, 2002; 39: 747-752.

3. Srinath S, Bharat S, Girimaji S, Sessadri S. Characteristics of a child inpatient population with hysteria in India. J Am Acad Child Adolsc Psychiatry 1993; 32: 822-825.

4. Adams WG. Rabies. In Nelson Text Book of Pediatrics 17th Ed. Beherman RE, Kliegman RM, Jenson HB. Editors. Saunders 2004: p 1101 -1104.