A Brief Summarize of Conversion Disorder Treatments

Review

A brief summarize of conversion disorder treatments

Altungy Labrador, P.

Universidad Complutense de Madrid

Little is known among the majority Nowadays, there are different of therapists about the Conversion approaches for disorder treatment, Disorder, and even less about the depending on the theoretical model used existent treatments. The idea of this for the intervention. Traditionally in our article is to explain the main treatments discipline, therapist used to select just that have been used so far in the clinical one theoretical approach and only their psychology, and the strengths and treatments, in a kind of “fight” against weaknesses of each one. The number of other psychological models that could studies in this field is not as exhaustive explain the disorder from other points of as it should be, considering the view. prevalence of this disorder in the However, nowadays most of population. Although since Janet’s time therapists acknowledge that a holistic there have not been remarkable point of view of the disorders is so developments in the field, in the last much useful than a restrictive one. This decades, cognitive-behavioural therapy, new (and unthinkable some decades along with pharmacological therapy, ago) view of the psychology, as a have been used in conversion disorder holistic discipline in which a disorder treatment with high effectiveness. can be explained from different models, Neuropsychological studies have is what currently we can find in offered new explanations for the conversion disorder treatment. So, disorder, due to neuroimage use. although we present the treatments Considering the information available classified under the model which about the disorder in the last ten years, “created” them, never forget that in conversion disorder can be considered present psychology, therapies from as an extreme stress response, so new different approaches are used together. treatments should consider this characteristic in order to improve the a) Psychodynamic treatments information known so far.

Psychoanalytic treatments were the The main idea for these therapists first in being used. Considering mental was that, through intensive dialogue, disorders as mainly caused by disorder could be solved. Therapist repression, therapists tried to work should be direct patient’s undercover those repressed emotions in thoughts, in order to help him to bring the patient, in order to allow them to stressful feeling to conscious. express their emotions in a healthy way. One of the techniques used by these The main tool used by them was, as is therapists was hypnosis. For its widely known, the psychoanalytic complexity and importance in dialogue, in which the therapist tried to conversion disorder treatment, it seems bring the repressed thoughts from the proper dedicate a specific part for its mind’s unconscious to the conscious. explanation. This way from the unconscious to the conscious part of the mind is not an II. Hypnosis easy job, so the use of complementary techniques to the dialogue seems Despite other times considered as strongly necessary. It is in this context one of the most effective treatments, in in which we include the two techniques the recent decades this psychological that, in our opinion, represent the most tool has been discredited, since the important ones along with the dialogue cognitive-behavioural establishment as per se. the paradigmatic one in psychology. Although not completely disappeared, I. Psychoanalytic therapy its use has been reduced mainly to psychodynamic therapists and some Rooted in Freud’s theories, psychiatrists (quite unknown among psychoanalytic therapy has been widely psychologists that most of psychiatrists used along last century and, of course, have a psychodynamic orientation). But for treating conversion disorder this general tendency it seems to be patients. Given that the first different in conversion disorder “psychological” definitions of the treatment. May it be due to the still disorder were made by psychoanalytic scarce knowledge about the disorder, therapists, it is clear why the main hypnosis is still considered as a useful conversion disorder therapies follow treatment for these patients. But if we this psychological model. talk about hypnosis, first it is necessary

2 talking about suggestion/self- dissociative symptomatology” (Roelofs suggestion. et al., 2002). Conversion disorder It was Janet who coined the term patients were compared with a control autohypnosis (Janet, 1907), which is a group. The results (table 8) showed that synonym for the nowadays more used conversion disorder patients were more concept self-suggestion. He purposed susceptible to hypnotic suggestions than that, in conversion disorder, patient control patients. As well, it was would autohypnotize himself in order to observed that the more susceptible a relief himself from the strong stress he patient was to hypnotic suggestion, the felt (Roelofs et al., 2002). This more symptoms he displayed. But, autohypnosis was the reason why, despite of these results, Roelofs et al. consequently, patient displayed (2002) purpose hypnotic suggestion somatoform symptoms (patient would susceptibility as a risk factor for have hypnotized himself some areas of developing conversion seizures, but not his brain, and the “hypnosis” of these a determinant factor. Even more, they areas would cause therefore the found that conversion patients were not symptomatology). only more susceptible to hypnotic So, having that in mind, it seems suggestions, but to nonhypnotic quite obvious which would be the suggestions (indirect suggestions) as disorder treatment: hypnotize the patient well. So, in the light of these results, again in order to allow the therapist to hypnotic suggestion cannot be unmake the patient self-hypnosis, bring considered as a determinant factor but his repressed stress out and, as result, as a risk factor. Despite of it, Roelofs et allow him to express it properly. al. (2002) study shows a strong support Some studies have been done in the for hypnosis therapy in conversion past decades, in order to find support for disorder patients. these previous assumptions (Goldstein et al., 2000). Roelofs et al. made a b) Cognitive-Behavioural treatments research under two main assumptions. The first one was that “patients with Despite conversion disorder is a well conversion disorder are highly known disorder since Egyptians time, it susceptible to hypnosis” The second is astonishing the lack of research in the assumption was that “hypnotic treatments field. Apart from the susceptibility is related to the

3 psychodynamic treatments mentioned patients’ shows, as it was explained before, which have been studied previously. So, what therapists have nowadays, are a bunch of treatments Table 8. Roelofs hypnosis study used for PNES in general, but almost no Control Conversion one of them specifically tested in patients patients (n=50) (n=50) conversion disorder patients. Anyway, a Measure M SD M SD Effect brief explanation of these treatments size SHSS-C* 3.9 2.6 5.6 3.1 0.6 from the cognitive-behavioural SDQ-20* 23.0 3.8 30.5 8.5 1.2 DES 9.1 7.9 11.7 11.0 0.3 approach is given. DIS-Q 1.8 0.5 1.8 0.7 0.0 Deeply rooted in learning theories, *Taken from Roelofs et al. (2002). SHSS-C: Stanford Hypnotic Susceptibility behavioural postulates have also Scale: Form C. integrated cognitive assumptions to SDQ-20: Somatoform Dissociation their model, with the result of the Questionnaire. paradigmatic psychological model DES: Dissociative Experiences Scale. nowadays. Because of that, treatments DIS-Q: Dissociation Questionnaire. will show traces from the very specifically for conversion disorder, traditional learning postulates, to the there are only other few examples of most recently cognitive psychological treatments specifically developed or assumptions. studied for conversion disorder. Which As the name indicates, cognitive- we can find for its treatment from a behavioural treatments will be cognitive-behavioural approach, are integrated by two different but therapies for Psychogenic Nonepileptic simultaneous techniques: the Seizures (PNES), among which we can behavioural and the cognitive. But, as classify conversion disorder. PNES are the name is, the intervention process is a group of mental seizures characterized integrated as well. For that, we talk for showing several different like- about Cognitive-Behavioural Therapy neurological seizures, which, indeed, (CBT). are not caused by neurological disorders This therapy is focused in two but psychological ones. The term processes: the primary and secondary “nonepileptical” is used because a high gain that the patient gets due to his percentage of the symptomatology is disorder. As it has been explained, almost identical to which epileptic patient gets two main benefits from his disorder: self-relief (primary gain) and

4 social attention (secondary gain). There -Phase B: make the patient is a specific intervention for each one. conscious of the irrational automatic As the primary gain is an internal thoughts that happen between the cognitive process, the most suitable stressful event and the anxiety state. therapy would be cognitive -Phase C: make the patient restructuring, as purposed by Ellis or conscious of his feelings and his Beck (we will explain their therapies anxious state, which come from later). For the secondary gain, a those automatic thoughts. behavioural approach seems more -Phase D: argue irrational thoughts suitable, due to the social nature of this discovered in phase B. process. -Phase E: lead patient (directly or Cognitive restructuring can be traced indirectly) in the codification of new back to the 50s, when Albert Ellis adaptative rational thoughts about the postulated a revolutionary treatment for stressful event and its consequences. anxiety and affective disorders. His -Phase F: help patient to codify the treatment is known as Rational Emotive new feelings that result from the new Behavioural Therapy (REBT) or ABC thoughts of phase E. model (Ellis, 1957). Ellis purposed that After this brief explanation of psychological disorders appeared due to Ellis’ model, now let’s show the cognitive distortions of internal and main techniques that therapist can external information. Hence, his use in order to achieve his goal: treatment goal was showing patient that -First of all, an explanation of the he was committing cognitive biases, and model is strongly recommended. that those biases were the main reason -After that, therapist should teach for his disorder. Ellis’ ABC model patient how to detect his established the following phases for automatic irrational thoughts. It is patient treatment (in order to adapt it to more difficult in the case of conversion disorder treatment, ABC conversion disorder patients, due model will be explained using stress as to their usually belle indifference example): to their symptomatology. -Phase A: establish the stressful -When patient realizes of those events that happen just before thoughts, an argument is patient’s anxiety state. necessary in order to help patient to change them.

-Eventually, therapist must that maintains it. Because of that, it encourage patient to consolidate is indispensable that therapist the new thoughts. explains (properly to each patient) Another approach to cognitive the disorder and the main reasons restructuring is given by Aaron Beck. why it is maintained. It will give the Originally created as a depression patient a feeling of control, which therapy, his cognitive therapy (Beck, will be fundamental in the 1979) is nowadays widely used for conversion disorder treatment. treating almost all kind of psychological 2. Training: it is necessary to train disorders (Figure 2). His model, as the patient in how detect his Ellis’s one, takes into account automatic automatic distorted thoughts. Maybe, cognitive distortions, but includes other this is the phase in which therapist variables, such basic cognitive schemes actions are more important. Through and the revolutionary concept of Socratic dialogue, therapist should cognitive triad (Beck, 1991). With the leads patient to realize those basic cognitive schemes concept, Beck cognitions and incongruences that somehow links the cognitive model may be in his speech. In conversion with the already traditional Freudian disorder, this phase could be even point of view. In addition, Beckian more important. As Janet said, la therapy model is more accurate that belle indifference usually means the Ellis’ REBT. The main points of the patient’s unacknowledged of neither beckian therapy are the following: symptoms nor stressful events that 1. Psychoeducation: one of the most caused the present conversion important assumptions in Beck’s disorder. So the acknowledge of model is that a proper psychological either symptomatology and causing understanding of the disorder is event are fundamental in this phase. necessary for changing the factors

3. Behavioural experiments: people around the patient. In this case, it finally, when patient has is necessary talking with patient family acknowledge his symptomatology, it and close social sphere, and explain is necessary to show him that he has them that no attention should be given not lost his motor or sensorial to patient’s conversion faculties, but are inhibited due to a symptomatology. Instead of it, attention stress response. Video records, should be directed to those behaviours automatic response elicitation and which are incompatible with conversion consecutive response approaches are behaviours. Those techniques are useful psychological tools in this known as extinction and differential final phase. reinforcement, and their intrinsic Until now, an explanation of how characteristic should be as well resolve the primary gain has been given explained to the patient’s family and to reader. It is time now for explaining friends. the main approaches to secondary gain Once the main points of the CBT solution. It this case, the therapy will have been shown, it is now turn for follow a more traditional behavioural presenting some concrete examples of approach. Secondary gain can be CBT application. conceived as the attention that a patient LaFrance (LaFrance et al., 2009) set gets due to his disorder. This gain is up a CBT program specific for patients sustained by an operational conditioning with PNES, among 2002 and 2007, with process. Disorder symptomatology is 21 patients, of whom 17 finished the reinforced by the attention provided by treatment. The therapy consisted in 12

7 individual one hour weekly sessions. Table 9. LaFrance CBT programme The therapy was led by a therapist with Session number Description more than ten years-experience. The Introduction Introduction for the sessions’ content is referred in table 9. patient: understanding seizures The results showed that “sixteen of the Session 1 Making the decision to twenty-one participants reported a 50% begin the process of reduction in seizure frequency, and taking control Session 2 Getting support eleven of the seventeen completers Session 3 Deciding about your reported no seizures per week by their medication therapy final CBT session”. Those results prove Session 4 Learning to observe that LaFrance CBT programme was your triggers effective, and he himself says that these Session 5 Channelling negative evidences open a door for conversion emotions into productive disorder patients (although study was outlets Session 6 Relaxation training not specific for conversion disorder Session 7 Identifying your patients). preseizure aura Other significative CBT efficacy Session 8 Dealing with external life stress study was conducted by Goldstein Session 9 Dealing with internal between 2001 and 2007 (Goldstein et issues and conflicts al., 2010). The aim of the study was Session 10 Enhancing personal checking the effectiveness of a CBT wellness: learning to reduce tensions programme applied to PNES patients Session 11 Other seizure symptoms (n=66). The importance of this study is Session 12 Taking control: an that is one of the few which has a ongoing process *Based on LaFrance et al. (2009). control group, whose patients (n=33) received Standard Medical Care (SMC), The treatment idea was making meanwhile the other 33 received the patients conscious of their CBT programme. Of the CBT symptomatology and explaining them programme group, 66.7% patients the reasons why they appeared and why attended to all sessions. The therapy they persist. The therapy also addressed consisted on 12 one hour-long weekly treatment for low self-esteem, low sessions, led by a CBT-trained nurse mood or anxiety problems (this last one therapist. is a very interesting one for conversion

8 disorder patients). Results show that recent years, our knowledge of brain CBT programme was so much effective working increased dramatically. It has in symptom reduction that SMC, which allowed us either to improve is the one usually given to PNES pharmacological therapies, as well as patients. understanding how they work. Despite there is no exhaustive Have we seen the neurobiological information about CBT effectiveness, it explanation for conversion disorder, is also true that there is the one which referred to a cortical temporary seizure has more support in the light of the in prefrontal cortex due to patient’s high results. More research must be done in stress-repressed levels. In recent years order to confirm this assumption but, another complementary explanation has until then, CBT programmes seem to be been given by several researchers the more accurate choice in conversion (LaFrance et al., 2010), an explanation disorder treatment. based on the serotonergic system. Along with conversion disorder, other c) Pharmacological treatments psychological disorders are usually present, disorders often related with Conversion disorder treatment based depression or anxiety. Serotonergic on a pharmacological therapy is a quite system is basically the main newly one. Although pharmacological neurotransmitter system implicated in therapy is not new in our discipline, last those disorders. LaFrance assumption two decades have provided us with a was that, if treating comorbid disorders deeper knowledge of how the pills work in PNES patients, its PNES symptoms in our nervous system. Until the 70s- would be reduced as result. Its 80s, all the information relative to pharmacological treatment choice was psychopharmacological therapy came using Serotonin Selective Reuptake from essay and trial studies. When a Inhibitors (SSRIs), specifically new medicament appeared, it was tested sertraline. This study is very important, into clinical population, and the results due to be the very first Randomized assessed. Sometimes those Control Trial (RCT) research performed pharmacological therapies worked, but for studying pharmacological therapy no exhaustive information about how effectiveness in PNES patients. could be given. With neuroimaging and As referred previously, amygdala biochemical techniques development in misregulation is believed to be the main

9 physiological problem in conversion verbalize both its feelings and the event disorder, which leads to ACC which probably caused the disorder. misregulation. Serotonin activity is Abreaction would work, theoretically, narrowly related with amygdala as hypnosis does, and the rest of the working. Increasing serotonin levels process would be the same. This could help in improving PNES technique is among psychodynamic and symptomatology. pharmacological techniques, but for the Results showed that sertraline group central play that drugs have, it has been reduced its PNES symptomatology in included here. Findings say that comparison with placebo group, abreaction is a useful technique, although limited sample size made moreover for patients with long-term impossible to generalize the results. resistant disorder. Despite of it, the development of a RCT study is an important step in As it has been presented, there are pharmacological conversion disorder different approaches for the treatment research. Anyway, it seems intervention, depending mainly of the plausible that future studies with proper explanation model used for the sample size will confirm the results that comprehension of the patient situation. LaFrance (2010) got. However, one thing in which almost Along with pharmacological everyone seems to agree is in linking treatment, CBT therapy is also conversion disorder with stress necessary in order to actually improve (anxiety). In this line, CBT treatments patient’s symptomatology. seem to be more or less the same which Other treatment which could be would be used in other anxiety included here is the abreaction disorders, and the results are quite good. technique (Poole, Wuerz, Agrawal, Considering it, one question that comes 2010). Abreaction is a technique in to my mind is, would not be better to which therapist interviews patient, who classify conversion disorder into anxiety is under the influence of a drug. The disorders? It is true that the idea of this method is to reduce the symptomatology is the characteristic of patient’s consciousness in order to let it somatoform disorders, but the disorder out the possible repressed feelings and origin seems to be in stressful events, anxiety which could be maintaining the exactly as in anxiety disorders. The disorder. Patient, in this situation, would point then is: what is more important for

10 the disorder classification and Psychology, 13: 38-44. understanding, its causes or its -Goldstein LH, Chalder T, Chigwedere symptoms? Maybe the answer of these C, Khondoker MR, Moriarty J, Toone questions are into the own DSM and BK, Mellers JDC. Cognitive-behavioral CIE classification criteria, which is therapy for psychogenic nonepileptic considering symptoms, not causes, due seizures. Neurology 2010;74:1986- to the impossibility of finding the 1994. certain origin of several disorders. So, -Goldstein LH, Drew C, Mellers J, although it could seem that the Mitchel-O'Malley S, Oakley DA. conversion disorder would fix better Dissociation, hypnotizability, coping into anxiety disorders group, styles and health locus of control: symptomatology classification criteria characteristics of pseudoseizure leads this disorder to somatoform patients. Seiure 2000;9:314-322. classification group. -Janet P. The major symptoms of Summarizing, further studies must be hysteria, 1907. done in order to improve the present -LaFrance WC, Miller IW, Ryan CE, knowledge available about conversion Blum AS, Solomon DA, Kelley JE, disorder, especially about its treatments. Keitner GI. Cognitive-behavioral These studies must follow the path therapy for psychogenic nonepileptic started in the first decade of the present seizures. Epilepsy & Behavior century, never forgetting the importance 2009;14:591-596. of statistical demands. -Poole NA, Wuerz A, Agrawal N. Abreaction for conversion disorder: References systematic review with meta-analysis. The British Journal of Psychiatry -Beck, A. Cognitive Therapy: A 30- 2010;197:91-95. year retrospective. American -Roelofs K, Hoogduin KAL, Keijsers Psychologist 1991; 46:368-375. GPJ, Näring GWB, Moene FC, -Beck, A. Cognitive Therapy of Sandijck P. Hypnotic susceptibility in Depression. Guildford Press, 1979. patients with conversion disorder. -Ellis, A. (1957). Rational Journal of Abnormal Psychology Psychotherapy and Individual 2002;111:390-395. Psychology. Journal of Individual