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The Treatment of Hysterical Blindness by Behavior Therapy
The Treatment of Hysterical Blindness by Behavior Therapy YOSHITERU OHNO, M.D., MINEYASU, SUGITA, M.S.W., TSUTOMU TAKEYA, M.D., MINORU AKAGI, M.D., YOSHIHARU TANAKA, M.D., AND YUJIRO IKEMI, M.D.
INTRODUCTION
There have been many reports on hysterical ophthalmic symptoms which include ophthalmocopia, blindness, color blindness, blepharospasm, blepharoptosis, photophobia and strabismus, but most of them deal with the mechanism and treatment from the psychodynamic standpoint. Behavior therapy,l.2 which is a new type of psychotherapy based on modern learning theory, has been drawing attention in Japan for the last few years. We have been applying this method to the treatment of psychosomatic or psychoneurotic patients and finding it quite effective. The present report concerns the application of learning theory to three patients of hysterical blindness and discussion of the general rules of treatment by behavior therapy. CASE REPORTS
Case 1: The patient was a 30 year old man and was admitted
to our University Hospital in November 1970 with the chief complaints of progressive loss of vision and headache. Apart from pulmonary tuberculosis at age 23, he had been in good health. There was no family history of mental illness. The patient was born as the third son of five siblings. His father was an office worker. The patient described him as stern and obstinate, whereas his mother was submissive and gentle. At age two the patient was adopted by a businessman but sent back to his own parents two years later. About this incident he had an intense feeling that he was treated with discrimination. At age five his oldest brother was hit by a car and injured himself in an attempt to protect the patient. There was no past history of eye disease. In adolescence he had several incidences of fainting while practicing "Judo" and "Karate". After graduating from a university, he started working for an electrical manufacturing company as a computer salesman. He was married in 1966 and had two children. On December 26, 1968 he was involved in a car accident, while riding in a taxi, and was hit on the head and chest. There was no loss of consciousness at that time and the pain disappeared soon after. Three months later, however he had nausea and general malaise and became unconscious for ten minutes on the way to a hospital. At that time he had frequent quarrels with his supervisor in regard to a business contract. In May 1969, when he reached a private settlement on the car accident, he noticed a blurring of vision (vision: left 1.0, right 0.2), and in October, photophobia began to appear. In the next two years he consulted with many ophthalmologists, neurologists and psychiatrists, but the vision of his both eyes became worse. He was admitted to our University Hospital on November 7, From Department of Psychosomatic Medicine, Faculty of Medicine, Kyushu University, Fukuoka City, Japan. April/MaylJune, 1974
1970 on the advice of a doctor who felt that his visual diminution was not due to the accident. At this time, neurological and ophthalmologic examinations were negative except for the diminution of vision (left 0.04, right 0) and a concentric contraction of the visual field. It should be added that the patient's salary was cut down 50% at the time of admis-~ion to the hospital. The patient was diagnosed as hysterical blindness and compensation neurosis. As his symptom seemed related to his maladjustment to work as well as to compensation for the accident, it was assumed that, in terms of behavior therapy, a conditioned avoidance respon3C from an anxiety had developed. It was likely that his persistent demand for compensation was in part related to aforementioned unfortunate experiences in childhood such as the adoption and the brother's injury in a car accident. His conditionability in the eyes might be related to the fainting spells, he had had while practicing "Judo" and "Karate" in adolescence. As we learned he had little possibility to get compensation for the accident on an organic basis and that he was expected to change his position in work, we applied a technique of behavior modification by use of suggestion. In it, the patient was given 10 mg of diazepam once a week intravenously and Flavitan eye lotion three times a week with the suggestion that his vision would generally become better. But the patient's symptom did not improve at all even after we applied this procedure for three months. In March 1971, we began with an operant conditioning technique, in which the patient was told that he would have training to increase his vision. In it, slides of nude girls were shown as positive reinforcers together with slides of landscapes as neutral stimuli. The ratio of these two kinds of slides was increased according to the extension of the distance between the patient and a slide. That is, first, ten landscape slides were shown from the distance in which he could see them well, then, nine landscape slides plus one nude slide 20 to 30 cm further than the previous distance, and finally ten nude slides. If he could identify seven out of the ten slides in one session, he was allowed to advance to the next session. After he practiced three or four such sessions a day for seven consecutive days, vision did improve very slightly. On March 19, 1971, his company told him that he would be fired unless he returned to work by May 20. It meant he would be in the worst economical condition. The vision was 0.06 on the left and 0.01 on the right on March 24. In April, his older brother came to see him and advised him to run a tax information office. In this connection, his brother indicated that he would be benefited by exemption if he could obtain a doctor's document that his vision would not recover. But the doctor in charge refused to issue such a certificate and insisted that his vision would surely improve. In a case conference on April 14, the use of an electrical stimulus as a negative reinforcer was suggested. Ten questions of simple arithmetic problems were shown one by one on the screen which was 20 cm further from the place he could see well. He was asked to answer the question within 15 seconds, and when he gave a wrong answer or no answer within this time limit, he was given a rather strong electrical stimulus 79
PSYCHOSOMATICS on his right leg. He had a chance to avoid the stimulus by giving correct answers. Before the application of this method, the patient was told that he should get accustomed to look at an object as hard as possible. This approach started on April 23, 1971 and the course of treatment is summarized in Table I. When the patient's answers were correct more than 70% in one session, he was allowed to advance to the next session, where the question was shown on the screen from 20 em further than it was in the previous session. When he reached to the distance of 210 em, it became difficult for him to give more than seven correct answers out of ten questions. Then he was allowed to advance to the next session. As the result, he could maintain 50% of the ratio of correct answers in spite of the rapid extension of the distance. We observed him very carefully during his performance and could not think of him performing like a blind man. On May 10, he had to leave the hospital because of economic reasons, but his vision was improved to 0.1 on the left and 0.04 on the right. In the outpatient clinic, we gave him brief interviews and some tranquilizers while he used his operant conditioning technique at home. This self-training consisted of recognizing a Japanese character of ten em:! in size from five meters away. In it, encouragement and admiration by his wife and children were used as a positive reinforcer. In July. his company told him that he had a chance to come back to his work, but he was hesitant to accept the proposal because of the lack of confidence in vision. Although his vision and visual field continued to improve little by little, he decided on official resignation from the company at the end of October. We began his reading practice in December, and in May 1972 he improved to the stage where he suffered no more inconveniences in daily life. In October 1972, his vision was 0.3 on
TABLE I OPERANT CONDITIONING BY ELECTRICAL STIMULI date 4123 24 26 27 28 29 30 5/1 2 3 4 6 7 8 80
distance em. 170 170 190 190 190 190 190 210 210 210 210 210 210 230 230 250 250 250 250 250 250 260 260 270 290 290 290
ratio of correct answers %
50 70 20 50 60 50 90 30 50 30 50 30 50 40 50 10 20 30 40 20 50 40 50 60 30 40 70
the left and 0.08 on the right with the long standing headache no longer present, It was thought in this case that the symptom had become chronic and persistent, forming a vicious cycle even though the original anxiety-provoking situation was no longer acting to exert a direct influence on the disease. In the initial stage, behavior modification by use of suggestion was applied in order to get rid of the symptom, but it turned out to be ineffective. Operant conditioning then was applied. Electrical stimulus and encouragement by the family members were effective as a reinforcer. Furthermore, the environmental manipulative procedure was used in order to eliminate a positive reinforcer for the persistence of the symptom, such as seen in the patient's request for a doctor's authentification for tax exemption, which emerged in the course of treatment. Case 2: The patient was 41 years old when he was admitted to our University Hospital in January 1970. That was his third admission. His chief complaints were progressive diminution of vision and photophobia. There was no family history of mental illness. He had conjunctivitis at age three, ekiri at six, pulmonary tuberculosis at seven, air hunger and hyperventilation syndrome at 22, irritable colon syndrome at 27. He was hospitalized twice to our hospital in 1962 and 1963 due to irritable colon syndrome, peripheral neuropathy and non-gaseous abdominal bloating of hysterical type.
He was born as the second son of two siblings. His father was an employee of a steel company. According to the patient, father was gentle but did not care for children, while mother was a woman of strong character always expecting her two sons to live independently. Although the patient was by nature weak physically, he was reckless in character often acting as a boss among his playmates. He remembered very well having a blurring of vision at age three when he had a discharge from the right eye due to conjunctivitis. He joined the air force at 15 during the war and crossed the death lines several times. He was discharged from the service in 1945 and in 1950 graduated from a university. In 1952 he joined the Self Defense Force where he lived an immoderate life, such as sleeping only two hours a day or drinking 3.6 liters of sake every night. Consequently he suffered from many disorders such as mentioned above. In 1955, he married a rather immature woman, whom he divorced three years later. He was soon married again to the present wife. Their marriage had no particular p~oblems. In October 1968, he was selected to take charge of a training program in operation research in Tokyo for one year. This was a strenuous task for him as he had to study differential calculus and integral calculus. On Ma~ch 12, 1969 when this program ended, he drank heavily at a farewell party and had a transient blurring of vision the following morning. He then came back to Fukuoka and found that he was responsible to make an annual plan of military operation by himself. It used to be that at least three people were assigned to this task. On March 23, when he was struggling with the plan without sleeping at night, he noticed a diminution of vision, fever, photophobia and eye pains. A week later, he was admitted to a national hospital with the vision of 0 on the left and 0.1 on the right. As his condition remained unchanged, he was admitted to our University Hospital on January 4, 1970. Neurological and ophthalmologic examinations were negative except for diminution of vision (left 0.1, right 0.1) and a concentric constriction of the visual field. A diagnosis of hysterical blindness was made on the assumption that his symptom was related to his strenuous work situation, by which a conditioned avoidance response from an anxiety had been developed. When in a difficult situation, he would work himself out by trying to accomVolume XV
HYSTERICAL BLINDNESS---OHNO ET AL plish an almost impossible task. This kind of self destructive trait might have been cultivated while he was in the military service during the war. A conditionability of the eye was possibly related to the conjunctivitis which he suffered when he was three. The patient had such an intense anxiety and fear about light due to photophobia and eye pain that he could not do without sunglasses even indoors. His therapy started first with desensitization to the light in vivo, that is, he was placed in a dark room which was gradually made brighter after he took off his sunglasses. His symptoms, however, did not improve even after eight sessions. We assumed, as a result, that his photophobia might be caused in part by the stimulation mediated by the trigeminal nerve. Thus two months after the hospitalization, we applied behavior modification by use of suggestion. The patient was given 0.3 g of Amobarbital intravenously once a week and 4% Xylocain eye lotion three times a week with the suggestion that his hypersensitivity to the light would disappear and the vision would be recovered. The rational for this approach was that Amobarbital was said to increase suggestibility and Xylocain eye lotion to eliminate photophobia caused by the irritation of the trigeminal nerve. This procedure proved to be most effective among all the approaches ever tried. Two weeks later, the patient was able to open the left eye and see the wall temporarily. In the middle of the second week, he could open his left eye for a longer period of time and the vision was improved, so that he could count his fingers at a distance of 30 cm. Three weeks later, the vision improved to 0.01 on the left and 0.4 on the right. At the end of March 1970, he had no difficulty in keeping his right eye open in the sun and no longer needed his sun glasses. On April 9, the vision was 0.4 on both eyes. In the meanwhile, environmental manipulative procedure was performed so that he could go back to a relatively easy post as an instructor of military history. He was not permitted to go out, read newspapers and watch television until he could see well. This was to let him experience inconveniences when blind. On May 15, 1970 the patient was discharged from our hospital after having been given an explanation for the formation of his symptom. Three years have passed since his discharge, and today (January 1974) he is working vigorously with the vision of 0.6 on the left and 0.4 on the right. Case 3: The patient was 20 years old when she was admitted to our University Hospital with the chief complaints of blurring of vision, headache and nausea. She had pneumonia at age 16, and her father has been sutlering from hypertension for many years. She was born on the farm as the third daughter of three girls. According to the patient, father was very gentle, almost foolishly honest, whereas mother was nagging but obliging. The patient had astigmatism in her high school days with the vision of 0.6 on the left and 0.8 on the right. There was no family nor past history of eye disease, but she had a tendency to suffer from eye pain and blurred vision when she was tired. After finishing her nurse's training in May 1971, she started working at an ENT hospital. One month later, she began to go with a man who had been a lover of her girl friend. In May 1972, she had difficulty in working with the doctor and nurses and changed to another hosiptal, which was a very busy place with a small staff. In September, she was about to marry the man. By way of gelling her final assurance, however, she went to a friend of her fiance to ask about the relationship between him and his former lover. She learned then that his former lover had had two artificial abortions in consequence of their sexual relations. Her pride being deeply hurt, she decided to break up with him, and their telephone contact stopped in September. In October, her supervising nurse got married and her responsibility at the hospital increased. In November she began to notice a blurring of vision in relation to insomnia. ApriI/May!June, 1974
On November 14, she received a telephone call from her former fiance asking her how she felt about his marrying another girl in a few months. It was the next day when she recognized that her vision diminished. After consulting ophthalmologists and neurologists, she was referred to our hospital on December 4, 1972. Neurological and ophthalmologic examinations were negative except for the diminution of vision (left 0.01, right 0.2). According to psychological evaluation, it was learned that the patient was a hysterical character with manifest anxiety which could easily be suppressed to cause inner tension. When the tension got unbearable, she would show an avoidance response such as self-abhorrence or frustration. A diagnosis of hysterical blindness was made on the basis of the assumption that her symptom was related to her marriage problem and maladjustment to her work. Thus a conditioned avoidance response from anxiety was thought to develop in her since she was prone to have blurred vision when she was tired. At the time of hospitalization, the patient complained of anorexia, insomnia and headache besides the diminution of vision. Together with medication for headache and insomnia, an interview was conducted twice a week. A month later, the patient talked about her love affair which seemed to be the kernel of her illness as she revealed intense anxiety, irritation, depressive feeling and insomnia. These symptoms required a prescription of Diazepam. On January 26, 1973 she learned that her former fiance was then married. Cornered in a desperate situation, she became anxious, irritable and depressed more than ever. We thought of the use of systematic desensitization in order to eliminate her anxiety, but had to give it up due to her overwhelming anxiety and the difficulty of such a therapy. Instead, she was encouraged to talk about her problems in a supportive and accepting atmosphere while she was placed under medication with Chlorpromazine (100 mg a day) every day. Through this technique, which apparently functioned as abreaction in terms of behavior therapy, the patient became less anxious, but there was no improvement in her vision. At this point, we applied behavior modification by suggestion. She was given suggestions that her vision would recover soon with the intravenous injection of 10 mg of Diazepam. After three sessions of this treatment on February 6, 13 and 15, her vision began to improve. It reached to 0.2 on the left and 0.5 on the right on February 16, and to 0.6 and 0.8 in March 1973. In addition to these procedures, an environmental manipulative procedure was applied. As the result, she quit her nursing profession and became a sales girl in a department store, where she is making a good adjustment after leaving our hospital eight months ago. DISCUSSION
Hysteria manifests specific psychophysiological symptoms which are non-organic but psychogenic. As Freud founded psychoanalysis upon his therapeutic experiences of hysteria by using hypnosis, most discussions concerning the symptom formation of hysteria so far have been had from the psychoanalytical standpoint. Eysenck,l on the other hand, thought that hysterical symptoms could be regarded as simple learned habits, which developed as a conditioned avoidance response in the face of an intense anxiety. Consequently, the elimination of a hysterical symptom might lead to the resurgence of anxiety. But clinically this is not always the case. Walton and Blackl reported a case of chronic hysteri81
PSYCHOSOMATICS
cal aphonia which originally developed as a conditioned avoidance response to anxiety, but continued to exist as only a habit afterwards. Case I in the present paper corresponds to this condition. The outlines of representative reports on the application of behavior therapy to the treatment of hysterical blindness are as follows: Brady and Lind 4 report on an experimental analysis of hysterical blindness by an operant conditioning technique. A 40 year old man was trained to space his responses within a certain period of time by pressing a button. A buzzer was to sound as a reward to a correctly spaced response. Then visual stimuli were added as cues for the correct response. In this way the patient's vision was said to have improved. Grosz and Zimmerman" conducted a follow-up study of the above-mentioned subject of Brady and Lind. They learned that his clinical improvement was rather short-lived. Later they" reported on a case of a 15 year old girl with functional blindness, who was somewhat improved by the operant procedure, but was cured spontaneously in the long run. Parry-Jones et aI.' reported on a case of a 47-year old woman with hysterical blindness. According to them, she was cured by use of a technique which was a modification of Brady and Lind's approach. It should be noted that in all these studies of hysterical blindness, rather complicated apparatuses had been used to assist the therapist in his behavior analysis or diagnosis. Later, those apparatuses were revised for treatment purposes, but actually they seemed rather impractical for daily clinical use. It is our own therapeutic experience that patients could be treated by behavior therapy without such apparatuses, if we follow the basic general rules. Such rules can be summarized as follows: I. An operant conditioning technique, behavior modification by suggestion and systematic desensitization
should be used in the situation where the symptom becomes chronic and persistent independently of the original anxiety-provoking stimulus. 2. In case the original anxiety-provoking situation still exists, therapy should be designed to decrease the anxiety as well as to eliminate the symptom. Such methods include systematic desensitization, assertive response, autogenic training. abreaction and environmental manipulative procedures. 3. When social conditions act as a positive reinforcer, as for example, other people's attitudes towards the patient's symptom, the environmental manipulative procedure can be used to eliminate such a reinforcer. Practically speaking, often these various procedures need to be properly combined depending on the situation. SUMMARY
In this paper, we have presented three case reports of hysterical blindness and discussed the application of behavior therapy to this disorder. Through our own therapeutic experiences, we have outlined the general rules which need to be kept in mind in the treatment of this disorder. REFERENCES
1. Eysenck, H. J.: Behavior Therapy and the Neuroses. Oxford: Pergamon Press, 1960. 2. Wolpe, J.: The Practice of Behavior Therapy. New York: Pergamon Press, 1969. 3. Walton, D. and Black, D. A.: J. Psychosom. Pres., 3:303, 1959. 4. Brady, J. P. and Lind, D. L.: Arch. Gen. Psychiat., 4:331, Apr. 1961. 5. Grosz, H. J. and Zimmerman, J.: Arch. Gen. Psychiat., 13 :255, Sept. 1965. 6. Grosz, H. J. and Zimmerman, J.: Behav. Ther., I: 115, 1970. 7. Parry-Jones, W. L. et al.: Belial'. Res. Ther., 8:79,1970.
Psychosomatic Ob-Gyn The Fourth International Congress of Psychosomatic Obstetrics and Gynecology will be held in Tel Aviv, Israel from October 27 to November 2, 1974. Full information can be obtained by writing to the Organizing Committee, P.D.B. 16271, Tel Aviv, Israel.
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Volume XV
INTRODUCTION
There have been many reports on hysterical ophthalmic symptoms which include ophthalmocopia, blindness, color blindness, blepharospasm, blepharoptosis, photophobia and strabismus, but most of them deal with the mechanism and treatment from the psychodynamic standpoint. Behavior therapy,l.2 which is a new type of psychotherapy based on modern learning theory, has been drawing attention in Japan for the last few years. We have been applying this method to the treatment of psychosomatic or psychoneurotic patients and finding it quite effective. The present report concerns the application of learning theory to three patients of hysterical blindness and discussion of the general rules of treatment by behavior therapy. CASE REPORTS
Case 1: The patient was a 30 year old man and was admitted
to our University Hospital in November 1970 with the chief complaints of progressive loss of vision and headache. Apart from pulmonary tuberculosis at age 23, he had been in good health. There was no family history of mental illness. The patient was born as the third son of five siblings. His father was an office worker. The patient described him as stern and obstinate, whereas his mother was submissive and gentle. At age two the patient was adopted by a businessman but sent back to his own parents two years later. About this incident he had an intense feeling that he was treated with discrimination. At age five his oldest brother was hit by a car and injured himself in an attempt to protect the patient. There was no past history of eye disease. In adolescence he had several incidences of fainting while practicing "Judo" and "Karate". After graduating from a university, he started working for an electrical manufacturing company as a computer salesman. He was married in 1966 and had two children. On December 26, 1968 he was involved in a car accident, while riding in a taxi, and was hit on the head and chest. There was no loss of consciousness at that time and the pain disappeared soon after. Three months later, however he had nausea and general malaise and became unconscious for ten minutes on the way to a hospital. At that time he had frequent quarrels with his supervisor in regard to a business contract. In May 1969, when he reached a private settlement on the car accident, he noticed a blurring of vision (vision: left 1.0, right 0.2), and in October, photophobia began to appear. In the next two years he consulted with many ophthalmologists, neurologists and psychiatrists, but the vision of his both eyes became worse. He was admitted to our University Hospital on November 7, From Department of Psychosomatic Medicine, Faculty of Medicine, Kyushu University, Fukuoka City, Japan. April/MaylJune, 1974
1970 on the advice of a doctor who felt that his visual diminution was not due to the accident. At this time, neurological and ophthalmologic examinations were negative except for the diminution of vision (left 0.04, right 0) and a concentric contraction of the visual field. It should be added that the patient's salary was cut down 50% at the time of admis-~ion to the hospital. The patient was diagnosed as hysterical blindness and compensation neurosis. As his symptom seemed related to his maladjustment to work as well as to compensation for the accident, it was assumed that, in terms of behavior therapy, a conditioned avoidance respon3C from an anxiety had developed. It was likely that his persistent demand for compensation was in part related to aforementioned unfortunate experiences in childhood such as the adoption and the brother's injury in a car accident. His conditionability in the eyes might be related to the fainting spells, he had had while practicing "Judo" and "Karate" in adolescence. As we learned he had little possibility to get compensation for the accident on an organic basis and that he was expected to change his position in work, we applied a technique of behavior modification by use of suggestion. In it, the patient was given 10 mg of diazepam once a week intravenously and Flavitan eye lotion three times a week with the suggestion that his vision would generally become better. But the patient's symptom did not improve at all even after we applied this procedure for three months. In March 1971, we began with an operant conditioning technique, in which the patient was told that he would have training to increase his vision. In it, slides of nude girls were shown as positive reinforcers together with slides of landscapes as neutral stimuli. The ratio of these two kinds of slides was increased according to the extension of the distance between the patient and a slide. That is, first, ten landscape slides were shown from the distance in which he could see them well, then, nine landscape slides plus one nude slide 20 to 30 cm further than the previous distance, and finally ten nude slides. If he could identify seven out of the ten slides in one session, he was allowed to advance to the next session. After he practiced three or four such sessions a day for seven consecutive days, vision did improve very slightly. On March 19, 1971, his company told him that he would be fired unless he returned to work by May 20. It meant he would be in the worst economical condition. The vision was 0.06 on the left and 0.01 on the right on March 24. In April, his older brother came to see him and advised him to run a tax information office. In this connection, his brother indicated that he would be benefited by exemption if he could obtain a doctor's document that his vision would not recover. But the doctor in charge refused to issue such a certificate and insisted that his vision would surely improve. In a case conference on April 14, the use of an electrical stimulus as a negative reinforcer was suggested. Ten questions of simple arithmetic problems were shown one by one on the screen which was 20 cm further from the place he could see well. He was asked to answer the question within 15 seconds, and when he gave a wrong answer or no answer within this time limit, he was given a rather strong electrical stimulus 79
PSYCHOSOMATICS on his right leg. He had a chance to avoid the stimulus by giving correct answers. Before the application of this method, the patient was told that he should get accustomed to look at an object as hard as possible. This approach started on April 23, 1971 and the course of treatment is summarized in Table I. When the patient's answers were correct more than 70% in one session, he was allowed to advance to the next session, where the question was shown on the screen from 20 em further than it was in the previous session. When he reached to the distance of 210 em, it became difficult for him to give more than seven correct answers out of ten questions. Then he was allowed to advance to the next session. As the result, he could maintain 50% of the ratio of correct answers in spite of the rapid extension of the distance. We observed him very carefully during his performance and could not think of him performing like a blind man. On May 10, he had to leave the hospital because of economic reasons, but his vision was improved to 0.1 on the left and 0.04 on the right. In the outpatient clinic, we gave him brief interviews and some tranquilizers while he used his operant conditioning technique at home. This self-training consisted of recognizing a Japanese character of ten em:! in size from five meters away. In it, encouragement and admiration by his wife and children were used as a positive reinforcer. In July. his company told him that he had a chance to come back to his work, but he was hesitant to accept the proposal because of the lack of confidence in vision. Although his vision and visual field continued to improve little by little, he decided on official resignation from the company at the end of October. We began his reading practice in December, and in May 1972 he improved to the stage where he suffered no more inconveniences in daily life. In October 1972, his vision was 0.3 on
TABLE I OPERANT CONDITIONING BY ELECTRICAL STIMULI date 4123 24 26 27 28 29 30 5/1 2 3 4 6 7 8 80
distance em. 170 170 190 190 190 190 190 210 210 210 210 210 210 230 230 250 250 250 250 250 250 260 260 270 290 290 290
ratio of correct answers %
50 70 20 50 60 50 90 30 50 30 50 30 50 40 50 10 20 30 40 20 50 40 50 60 30 40 70
the left and 0.08 on the right with the long standing headache no longer present, It was thought in this case that the symptom had become chronic and persistent, forming a vicious cycle even though the original anxiety-provoking situation was no longer acting to exert a direct influence on the disease. In the initial stage, behavior modification by use of suggestion was applied in order to get rid of the symptom, but it turned out to be ineffective. Operant conditioning then was applied. Electrical stimulus and encouragement by the family members were effective as a reinforcer. Furthermore, the environmental manipulative procedure was used in order to eliminate a positive reinforcer for the persistence of the symptom, such as seen in the patient's request for a doctor's authentification for tax exemption, which emerged in the course of treatment. Case 2: The patient was 41 years old when he was admitted to our University Hospital in January 1970. That was his third admission. His chief complaints were progressive diminution of vision and photophobia. There was no family history of mental illness. He had conjunctivitis at age three, ekiri at six, pulmonary tuberculosis at seven, air hunger and hyperventilation syndrome at 22, irritable colon syndrome at 27. He was hospitalized twice to our hospital in 1962 and 1963 due to irritable colon syndrome, peripheral neuropathy and non-gaseous abdominal bloating of hysterical type.
He was born as the second son of two siblings. His father was an employee of a steel company. According to the patient, father was gentle but did not care for children, while mother was a woman of strong character always expecting her two sons to live independently. Although the patient was by nature weak physically, he was reckless in character often acting as a boss among his playmates. He remembered very well having a blurring of vision at age three when he had a discharge from the right eye due to conjunctivitis. He joined the air force at 15 during the war and crossed the death lines several times. He was discharged from the service in 1945 and in 1950 graduated from a university. In 1952 he joined the Self Defense Force where he lived an immoderate life, such as sleeping only two hours a day or drinking 3.6 liters of sake every night. Consequently he suffered from many disorders such as mentioned above. In 1955, he married a rather immature woman, whom he divorced three years later. He was soon married again to the present wife. Their marriage had no particular p~oblems. In October 1968, he was selected to take charge of a training program in operation research in Tokyo for one year. This was a strenuous task for him as he had to study differential calculus and integral calculus. On Ma~ch 12, 1969 when this program ended, he drank heavily at a farewell party and had a transient blurring of vision the following morning. He then came back to Fukuoka and found that he was responsible to make an annual plan of military operation by himself. It used to be that at least three people were assigned to this task. On March 23, when he was struggling with the plan without sleeping at night, he noticed a diminution of vision, fever, photophobia and eye pains. A week later, he was admitted to a national hospital with the vision of 0 on the left and 0.1 on the right. As his condition remained unchanged, he was admitted to our University Hospital on January 4, 1970. Neurological and ophthalmologic examinations were negative except for diminution of vision (left 0.1, right 0.1) and a concentric constriction of the visual field. A diagnosis of hysterical blindness was made on the assumption that his symptom was related to his strenuous work situation, by which a conditioned avoidance response from an anxiety had been developed. When in a difficult situation, he would work himself out by trying to accomVolume XV
HYSTERICAL BLINDNESS---OHNO ET AL plish an almost impossible task. This kind of self destructive trait might have been cultivated while he was in the military service during the war. A conditionability of the eye was possibly related to the conjunctivitis which he suffered when he was three. The patient had such an intense anxiety and fear about light due to photophobia and eye pain that he could not do without sunglasses even indoors. His therapy started first with desensitization to the light in vivo, that is, he was placed in a dark room which was gradually made brighter after he took off his sunglasses. His symptoms, however, did not improve even after eight sessions. We assumed, as a result, that his photophobia might be caused in part by the stimulation mediated by the trigeminal nerve. Thus two months after the hospitalization, we applied behavior modification by use of suggestion. The patient was given 0.3 g of Amobarbital intravenously once a week and 4% Xylocain eye lotion three times a week with the suggestion that his hypersensitivity to the light would disappear and the vision would be recovered. The rational for this approach was that Amobarbital was said to increase suggestibility and Xylocain eye lotion to eliminate photophobia caused by the irritation of the trigeminal nerve. This procedure proved to be most effective among all the approaches ever tried. Two weeks later, the patient was able to open the left eye and see the wall temporarily. In the middle of the second week, he could open his left eye for a longer period of time and the vision was improved, so that he could count his fingers at a distance of 30 cm. Three weeks later, the vision improved to 0.01 on the left and 0.4 on the right. At the end of March 1970, he had no difficulty in keeping his right eye open in the sun and no longer needed his sun glasses. On April 9, the vision was 0.4 on both eyes. In the meanwhile, environmental manipulative procedure was performed so that he could go back to a relatively easy post as an instructor of military history. He was not permitted to go out, read newspapers and watch television until he could see well. This was to let him experience inconveniences when blind. On May 15, 1970 the patient was discharged from our hospital after having been given an explanation for the formation of his symptom. Three years have passed since his discharge, and today (January 1974) he is working vigorously with the vision of 0.6 on the left and 0.4 on the right. Case 3: The patient was 20 years old when she was admitted to our University Hospital with the chief complaints of blurring of vision, headache and nausea. She had pneumonia at age 16, and her father has been sutlering from hypertension for many years. She was born on the farm as the third daughter of three girls. According to the patient, father was very gentle, almost foolishly honest, whereas mother was nagging but obliging. The patient had astigmatism in her high school days with the vision of 0.6 on the left and 0.8 on the right. There was no family nor past history of eye disease, but she had a tendency to suffer from eye pain and blurred vision when she was tired. After finishing her nurse's training in May 1971, she started working at an ENT hospital. One month later, she began to go with a man who had been a lover of her girl friend. In May 1972, she had difficulty in working with the doctor and nurses and changed to another hosiptal, which was a very busy place with a small staff. In September, she was about to marry the man. By way of gelling her final assurance, however, she went to a friend of her fiance to ask about the relationship between him and his former lover. She learned then that his former lover had had two artificial abortions in consequence of their sexual relations. Her pride being deeply hurt, she decided to break up with him, and their telephone contact stopped in September. In October, her supervising nurse got married and her responsibility at the hospital increased. In November she began to notice a blurring of vision in relation to insomnia. ApriI/May!June, 1974
On November 14, she received a telephone call from her former fiance asking her how she felt about his marrying another girl in a few months. It was the next day when she recognized that her vision diminished. After consulting ophthalmologists and neurologists, she was referred to our hospital on December 4, 1972. Neurological and ophthalmologic examinations were negative except for the diminution of vision (left 0.01, right 0.2). According to psychological evaluation, it was learned that the patient was a hysterical character with manifest anxiety which could easily be suppressed to cause inner tension. When the tension got unbearable, she would show an avoidance response such as self-abhorrence or frustration. A diagnosis of hysterical blindness was made on the basis of the assumption that her symptom was related to her marriage problem and maladjustment to her work. Thus a conditioned avoidance response from anxiety was thought to develop in her since she was prone to have blurred vision when she was tired. At the time of hospitalization, the patient complained of anorexia, insomnia and headache besides the diminution of vision. Together with medication for headache and insomnia, an interview was conducted twice a week. A month later, the patient talked about her love affair which seemed to be the kernel of her illness as she revealed intense anxiety, irritation, depressive feeling and insomnia. These symptoms required a prescription of Diazepam. On January 26, 1973 she learned that her former fiance was then married. Cornered in a desperate situation, she became anxious, irritable and depressed more than ever. We thought of the use of systematic desensitization in order to eliminate her anxiety, but had to give it up due to her overwhelming anxiety and the difficulty of such a therapy. Instead, she was encouraged to talk about her problems in a supportive and accepting atmosphere while she was placed under medication with Chlorpromazine (100 mg a day) every day. Through this technique, which apparently functioned as abreaction in terms of behavior therapy, the patient became less anxious, but there was no improvement in her vision. At this point, we applied behavior modification by suggestion. She was given suggestions that her vision would recover soon with the intravenous injection of 10 mg of Diazepam. After three sessions of this treatment on February 6, 13 and 15, her vision began to improve. It reached to 0.2 on the left and 0.5 on the right on February 16, and to 0.6 and 0.8 in March 1973. In addition to these procedures, an environmental manipulative procedure was applied. As the result, she quit her nursing profession and became a sales girl in a department store, where she is making a good adjustment after leaving our hospital eight months ago. DISCUSSION
Hysteria manifests specific psychophysiological symptoms which are non-organic but psychogenic. As Freud founded psychoanalysis upon his therapeutic experiences of hysteria by using hypnosis, most discussions concerning the symptom formation of hysteria so far have been had from the psychoanalytical standpoint. Eysenck,l on the other hand, thought that hysterical symptoms could be regarded as simple learned habits, which developed as a conditioned avoidance response in the face of an intense anxiety. Consequently, the elimination of a hysterical symptom might lead to the resurgence of anxiety. But clinically this is not always the case. Walton and Blackl reported a case of chronic hysteri81
PSYCHOSOMATICS
cal aphonia which originally developed as a conditioned avoidance response to anxiety, but continued to exist as only a habit afterwards. Case I in the present paper corresponds to this condition. The outlines of representative reports on the application of behavior therapy to the treatment of hysterical blindness are as follows: Brady and Lind 4 report on an experimental analysis of hysterical blindness by an operant conditioning technique. A 40 year old man was trained to space his responses within a certain period of time by pressing a button. A buzzer was to sound as a reward to a correctly spaced response. Then visual stimuli were added as cues for the correct response. In this way the patient's vision was said to have improved. Grosz and Zimmerman" conducted a follow-up study of the above-mentioned subject of Brady and Lind. They learned that his clinical improvement was rather short-lived. Later they" reported on a case of a 15 year old girl with functional blindness, who was somewhat improved by the operant procedure, but was cured spontaneously in the long run. Parry-Jones et aI.' reported on a case of a 47-year old woman with hysterical blindness. According to them, she was cured by use of a technique which was a modification of Brady and Lind's approach. It should be noted that in all these studies of hysterical blindness, rather complicated apparatuses had been used to assist the therapist in his behavior analysis or diagnosis. Later, those apparatuses were revised for treatment purposes, but actually they seemed rather impractical for daily clinical use. It is our own therapeutic experience that patients could be treated by behavior therapy without such apparatuses, if we follow the basic general rules. Such rules can be summarized as follows: I. An operant conditioning technique, behavior modification by suggestion and systematic desensitization
should be used in the situation where the symptom becomes chronic and persistent independently of the original anxiety-provoking stimulus. 2. In case the original anxiety-provoking situation still exists, therapy should be designed to decrease the anxiety as well as to eliminate the symptom. Such methods include systematic desensitization, assertive response, autogenic training. abreaction and environmental manipulative procedures. 3. When social conditions act as a positive reinforcer, as for example, other people's attitudes towards the patient's symptom, the environmental manipulative procedure can be used to eliminate such a reinforcer. Practically speaking, often these various procedures need to be properly combined depending on the situation. SUMMARY
In this paper, we have presented three case reports of hysterical blindness and discussed the application of behavior therapy to this disorder. Through our own therapeutic experiences, we have outlined the general rules which need to be kept in mind in the treatment of this disorder. REFERENCES
1. Eysenck, H. J.: Behavior Therapy and the Neuroses. Oxford: Pergamon Press, 1960. 2. Wolpe, J.: The Practice of Behavior Therapy. New York: Pergamon Press, 1969. 3. Walton, D. and Black, D. A.: J. Psychosom. Pres., 3:303, 1959. 4. Brady, J. P. and Lind, D. L.: Arch. Gen. Psychiat., 4:331, Apr. 1961. 5. Grosz, H. J. and Zimmerman, J.: Arch. Gen. Psychiat., 13 :255, Sept. 1965. 6. Grosz, H. J. and Zimmerman, J.: Behav. Ther., I: 115, 1970. 7. Parry-Jones, W. L. et al.: Belial'. Res. Ther., 8:79,1970.
Psychosomatic Ob-Gyn The Fourth International Congress of Psychosomatic Obstetrics and Gynecology will be held in Tel Aviv, Israel from October 27 to November 2, 1974. Full information can be obtained by writing to the Organizing Committee, P.D.B. 16271, Tel Aviv, Israel.
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