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Somatic Therapy for Conversion Disorder
Letters Somatic Therapy for Conversion Disorder SIR: The article "Factitious Physical Disorders: Treatment Without Confrontation." by Dr. Stuart J. Eisendrath; has prompted me to report a patient with conversion disorder who was treated in a similar manner.
Case Report An 18-year-old black woman was admitted to the neurosurgery service after the acute onset of rightarm pain and paralysis. Three weeks prior to admission. she had sustained a mild cervical strain when the train on which she was riding stopped suddenly. On the night prior to admission. she experienced suicidal ideation and hid a razor blade beneath the mattress for possible future use. Neurological evaluation. including an electromyogram (EMG) and nerve conduction stUdies. was normal. without evidence of brachial plexus injury or cervical radiculopathy. The patient was told that her paralysis could be emotionally related. and she readily accepted transfer to the psychiatric unit. She was treated with psychotherapy and physiotherapy. which consisted of activities designed to induce usage of her right arm. A pUlley system was used to facilitate shoulder flexion and abduction. and exercises were provided to increase the range of motion of her right shoulder. In addition. she was given activities to facilitate wrist extension and fine motor coordination in the right hand. Various eye-hand coordination exercises were used. including pegboard and writing activities. The patient regained full strength and motor function within three weeks. She was discharged and referred for outpatient psychotherapy. There were no further conversion symptoms at the time of follow-up seven years later.
Ford2 noted that most conversion reactions remit spontaneously or with minimal suggestion. Psychotherapy. hypnosis. and sodium amobarbital may be helpful. while direct confrontation is seldom productive. 3 As Eisendrath observed. "When dealing with behavior with prominent unconscious motivation such as conversion reactions ...the therapist provides no benefit by revealing understanding of the psychological processes too early in the treatment" (p. 386). VOLUME 31' NUMBER 3· SUMMER 1990
The adjunctive use of somatic therapies in the treatment of conversion disorder has been explored in a limited number of cases. Hafeiz4 found that suggestion under faradic stimulation produced a 90% remission with minimal symptom substitution. Dickes5 reported a series of 16 patients with conversion reactions. two of whom were treated successfully with psychotherapy and orthopedic treatment. However. the nature of the orthopedic intervention was not described. The patient described here received physical therapy as the primary treatment. Treatment also incorporated the strategies advocated by Dr. Eisendrath l for patients with factitious disorders. We refrained from confrontation. gave an inexact interpretation of the cause of the paralysis (that the symptom could be emotionally related). and allowed the patient to "save face" by offering her physiotherapy. We believed that the risk involved in "legitimizing" her illness was justified in light of studies45 that show a poorer prognosis with increasing duration of untreated symptoms. Arthur Lazarus. M.D. Philadelphia Psychiatric Center Philadelphia. Pennsylvania
References 1. Eisendrath SJ: Factitious physical disorders: treatment
2. 3. 4. 5.
without confrontation. Psychosomatics 30:383-387. 1989 Ford CV: The Somati:in[? Disorders: I/Iness as a Way of Life. New York. Elsevier. 1983 Lazare A: Current concepts in psychiatry: conversion symptoms. N En[?1 J Med 305:745-748. 1981 Hafeiz HB: Hysterical conversion: a prognostic study. Br J Psychiatry 136:548-551. 1980 Dickes RA: Brief therapy of conversion reactions: an in-hospital technique. Am J Psychiatry 131 :584-586. 1974
In Reply SIR: Thank you for the opportunity to respond to Dr. Lazarus's thoughtful letter. His successful utilization of somatic therapy in a patient with a conversion disorder highlights the value of a nonconfrontational approach to many such patients. Patients with abnormal illness behavior (e.g.• factitious illness or conversion disorders) 357
Case Report An 18-year-old black woman was admitted to the neurosurgery service after the acute onset of rightarm pain and paralysis. Three weeks prior to admission. she had sustained a mild cervical strain when the train on which she was riding stopped suddenly. On the night prior to admission. she experienced suicidal ideation and hid a razor blade beneath the mattress for possible future use. Neurological evaluation. including an electromyogram (EMG) and nerve conduction stUdies. was normal. without evidence of brachial plexus injury or cervical radiculopathy. The patient was told that her paralysis could be emotionally related. and she readily accepted transfer to the psychiatric unit. She was treated with psychotherapy and physiotherapy. which consisted of activities designed to induce usage of her right arm. A pUlley system was used to facilitate shoulder flexion and abduction. and exercises were provided to increase the range of motion of her right shoulder. In addition. she was given activities to facilitate wrist extension and fine motor coordination in the right hand. Various eye-hand coordination exercises were used. including pegboard and writing activities. The patient regained full strength and motor function within three weeks. She was discharged and referred for outpatient psychotherapy. There were no further conversion symptoms at the time of follow-up seven years later.
Ford2 noted that most conversion reactions remit spontaneously or with minimal suggestion. Psychotherapy. hypnosis. and sodium amobarbital may be helpful. while direct confrontation is seldom productive. 3 As Eisendrath observed. "When dealing with behavior with prominent unconscious motivation such as conversion reactions ...the therapist provides no benefit by revealing understanding of the psychological processes too early in the treatment" (p. 386). VOLUME 31' NUMBER 3· SUMMER 1990
The adjunctive use of somatic therapies in the treatment of conversion disorder has been explored in a limited number of cases. Hafeiz4 found that suggestion under faradic stimulation produced a 90% remission with minimal symptom substitution. Dickes5 reported a series of 16 patients with conversion reactions. two of whom were treated successfully with psychotherapy and orthopedic treatment. However. the nature of the orthopedic intervention was not described. The patient described here received physical therapy as the primary treatment. Treatment also incorporated the strategies advocated by Dr. Eisendrath l for patients with factitious disorders. We refrained from confrontation. gave an inexact interpretation of the cause of the paralysis (that the symptom could be emotionally related). and allowed the patient to "save face" by offering her physiotherapy. We believed that the risk involved in "legitimizing" her illness was justified in light of studies45 that show a poorer prognosis with increasing duration of untreated symptoms. Arthur Lazarus. M.D. Philadelphia Psychiatric Center Philadelphia. Pennsylvania
References 1. Eisendrath SJ: Factitious physical disorders: treatment
2. 3. 4. 5.
without confrontation. Psychosomatics 30:383-387. 1989 Ford CV: The Somati:in[? Disorders: I/Iness as a Way of Life. New York. Elsevier. 1983 Lazare A: Current concepts in psychiatry: conversion symptoms. N En[?1 J Med 305:745-748. 1981 Hafeiz HB: Hysterical conversion: a prognostic study. Br J Psychiatry 136:548-551. 1980 Dickes RA: Brief therapy of conversion reactions: an in-hospital technique. Am J Psychiatry 131 :584-586. 1974
In Reply SIR: Thank you for the opportunity to respond to Dr. Lazarus's thoughtful letter. His successful utilization of somatic therapy in a patient with a conversion disorder highlights the value of a nonconfrontational approach to many such patients. Patients with abnormal illness behavior (e.g.• factitious illness or conversion disorders) 357