Re:Conversion Disorder

Dear Donna

It's often important in conversion disorder to combine psychological treatment with physical rehabilitation. I'm not up on published research, but on the basis of discussions with colleagues and my own experience, rehabilitation is often the key element, and developing a good collaborative relationship with the physiotherapist and occupational therapist treating the patient can be more important initially than any other part of the intervention. Although conversion disorder used to characterised as presenting following a dramatic life event, it is now acknowledged that it most often arises from a more subtle dilemma faced by the patient, for which the patient sees no solution.

In this case, it sounds as though rehabilitation was started, but I'm not sure whether the therapist(s) persisted with it? Some physical therapists (at least in the UK!) find it hard to work with people who have no physical basis for their disabilities, and here liaison with the cognitive therapist might be helpful.

Another important element of conceptualisation concerns the attitude of partners and others close to the patient, and their responses to the patient's symptoms. If the problem in this instance appears to have arisen because of something to do with the relationship between the patient and her partner, it might be very difficult for the patient to simply acknowledge that 'there's nothing physically wrong' , however often the partner reminds her of this. This could be explored by reviewing how the patient perceives her partner's understanding and attitudes, and what she would find most helpful from her partner. Involving the partner in this is commonly helpful too, but in my experience, it's best to try to understand the two (often contradicting) views before seeing them together. It's sometimes necessary to shift the patient's and partner's focus from the present and/or past to the future - the question the patient and/or partner sometimes become preoccupied with is 'What caused this to happen?' rather than 'what needs to be done to get things better?'. While there is disagreement on the former, it's often difficult to make any progress on the latter. Negotiating a shared understanding of the reasons for the symptoms may be helpful, so long as it doesn't become all consuming. A model that I've heard described recently but haven't yet applied myself is hypnotism - most people acknowledge that while hynotised, individuals can behave in strikingly unusual ways, even though their brains or their 'personalities' have not been changed. This may be a plausible compromise between the patient's view that 'there is something neurologically wrong' and the partner's view (apparently) that no abnormalities were discovered to account for the problem. If things get stuck at the 'how did this happen stage', it's probably best to try to negotiate with the patient (and perhaps also the partner) to reserve judgement on this as currently unknown, and to focus on what can be done to limit distress and disabilities.

I'd certainly also treat the depression. In this case, I'd consider using antidepressants as well as cognitive therapy, not least because if antidepressants offer benefit, this is yet another example of the complex links between 'mind' and 'body' which might allow the patient and her partner to think more flexibly about her other symptoms.

As an aside, I should note that research into conversion disorders was set back several decades by the prospective study some years ago done at the National Hospitals, Queen Square here in London (at the time the major tertiary centre for neurology) which showed that people presenting with hysteria followed up an average of 11 years later were very likely to have developed manifestations of serious neurology disorders. This led to British psychiatry (prematurely) rejecting hysteria as a diagnosis and it's only in recent years that we psychiatrists in the UK have listened to our neurologist colleagues, who have of course continued to see cases regularly. Studies after the National Hospital study all failed to replicate its findings, and it is now clear that conversion disorders very rarely present as prodromal manifestations of other neurological conditions.

Yours

Tom

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