Re:Conversion Disorder

Dear Donna,

Last year, I mentioned a case I was treating with CT, although I had no experience with CT in conversion disorder. The case report is attached. I apologise for any mistakes as the text has not been revised by an English-speaking native.

Irismar Reis de Oliveira
Salvador-Bahia, Brazil

M. is an 18-year-old female inpatient presenting with complete paralysis of the right arm and neck since she was sixteen. She had no apparent psychological disorder until 2 years ago, when she was physically aggressed by a policeman and arrested for one night. Examination at the time and also recently did not show any sign of neurological damage. She stopped secondary school and was seen by several physicians (neurologists and psychiatrists) and physiotherapists in the last two years.

Present hospitalization was proposed because she presented depressive symptoms and suicidal ideation. “I cannot stand being different and not to be able to use my arm. I cannot go close to a window without feeling like to jump”, she said.
We decided to try cognitive therapy in order to help her improve from depression and anxiety. Indeed I did not expect her to improve from her deficit. During the sessions described below, besides the diagnosis of conversion disorder, she has demonstrated to fulfill the criteria for attention deficit disorder.

INTERVIEWS

Session 1
The first interview was dedicated to collecting M.’s story and to assessing diagnosis as well as her mood. She had a DSM-IV diagnosis of major depressive episode. Her Beck Depression Inventory (BDI) score was 40. Although this score was rather high, I did not consider that she had a severe depression, as she was able to laugh and to take part in the activities in the ward without apparent difficulties.
She was first introduced to the cognitive model. She was also asked to devise goals to attain in the next two months. Her goals were: (i) recover movements of the arm and neck, (ii) control bursts of anger and (iii) think differently.
When she was asked what she would be doing if she started to think differently, she said she would be able to have a better relationship with people.

I taught her how to use Dysfunctional Thought Record (DTR). Below is the first situation she thought about. It took place in the morning. The percentages mean how much she believed in the thoughts and how strong were the emotions.

Situation: Waiting for somebody to visit her.
Automatic thought (AT): I am alone. My parents abandoned me. They did not want to come to Salvador with me (85%). (Salvador is the capital of the Sate of Bahia, Brazil)
Emotion: sadness (85%).
Alternative responses (ARs): i) My parents live in a farm. It is difficult for them to travel (100%). ii) My father is shy. He does not like to come to the city (100%). iii) Mother tried to help mebefore (100%).
Results: AT (50%) Sadness (60%)

As homework, she was asked to practice DTR. Our contract was that we would have three one-hour sessions while she was in the hospital and then she would have a one-hour session weekly.

Session 2
Next day, a few minutes before the session, she had a burst of anger and destroyed the support for her neck into small pieces with the teeth. She was helped to come to the office because, without the support, her head fell to the side and she lost equilibrium, not being able to walk.

After a brief summary of last session, she was asked to write down her automatic thought (ATs) concerning the above situation: “I am suffering in the hospital and the person who did this to me is free and well. Destroying him and his family or destroying myself does not make any difference”. So I proposed her to write down the advantages and disadvantages of forgetting the aggressor or taking vengeance.

Table 1. Advantages and disadvantages.

To forget the aggressor:

Advantages:
Sleep well again
Recuperate well-being and happiness
Use energy for work, study and having fun
Getting better with other people

Disadvantages:
Nothing changes and the aggressor does not pay for what he did to me

To take vengeance:

Advantages:
Feeling of relief

Disadvantages:
Emotional burden
I may be punished and go to jail if I succeed. Even if he did not pay, I shall pay a high price if I take vengeance. I may be so involved to the point of self-destruction. This may be a victory for the aggressor.

As a result of this exercise, she concluded that it was not worthy to take vengeance. “I only lose”, she said.

Session 3
Before session 3, she was found crying because “nurses who helped me with my bath were mean to me. It is not my fault if I cannot keep my head straight”. The ATs “It would be better if I died” and “They want to humiliate me” and several other automatic thoughts appeared and were analyzed with the DTR technique. At the end of the session, M. was feeling less sad and anxious. Part of this session was used to investigate the diagnosis of attention deficit disorder (ADD), as she was very forgetful and impulsive since she was a child. She had had frequent disciplinary problems and difficulty to learn during her school years. Indeed, I had noticed that she was very distracted during sessions.

Session 4
M. came to session 4 as an outpatient. This session was used to further familiarize her with DTR and the relationship between ATs, emotions and her bursts of anger. I also tried to introduce the concept of core beliefs and schemas but she seemed not to understand them. So I postponed this intention. Although she seemed not depressed, her BDI score was 20, half of the initial one.

Session 5
She complained of pain in the fingers of her paralyzed hand because she had tried to hold the cloth with them and wash it with the non-paralyzed hand. I suggested that, if the fingers were painful, maybe it was because she was already using them, that maybe her movements were coming back. Why did not she try to move them now? And so she did. She started to move the fingers first, then the hand, then she was able to turn the arm and finally to rise the hand and the arm from the table. She could also write her name.

Sessions 6-7
Forgetful and distracted again, making progress difficult. “I do not remember” was the sentence she used more frequently. Despite this, some behaviour experiments, showed that she could recall when stimulated. In session 7, she was able to stand her head without support and the movements of the arm were more complete, showing gradual return of muscle strength. We discussed the convenience of prescribing methylphenydate, decision to be taken in the next session.

Sessions 8-11
Our intent was to consolidate the results obtained above, which was achieved more easily after methylphenydate was started. Her capacity of paying attention was better and she started to participate more actively in the sessions. We decided to stop cognitive therapy in session 10 because I had to travel. At this moment M. was well, taking care of an old lady. Her only sequel is a luxation of the right shoulder for not using it for almost two years.

Now, almost a year later, she comes every month to receive her methylphenydate prescription. She studies, still works (taking care of the old lady), and studies in the evening period.

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