Cognitive-Behavioral Therapy in the case of a teenager with conversion disorder with mixed presentation
Children and Adolescents Psychiatric Clinic
Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca
This paper discusses a cognitive-behavioral therapeutic intervention combined with suggestive therapy and the use of a chemical agent (placebo) in the case of a 13- year old teenager, named “Suzi”, hospitalized several times for conversion disorder with mixed presentation. Symptoms were different from one hospital admittance to the other, and initially included chronic vomiting, then rebel headaches and opisthotonos with lower limbs trembling and crying, functional facial paralysis, non-kinetic mutism with language regression, lower limbs hypotony, major walking disorders and fainting episodes.
From a psychological point of view, her mother describes her as being sensitive, hyperemotional, emotionally unstable, anxious, impressionable, and loving to be the center of attention. The teenager’s family was in harmony, but in conflict with one neighboring family. The polymorph symptoms were interpreted as conversion disorder occurring in a conflict situation, and based on a developing personality with sensitive and histrionic traits. We initiated a cognitive-behavioral and suggestive therapy combined with the use of a chemical agent (placebo). A favorable evolution was noticed with every hospitalization.
Key words: conversion disorder, cognitive-behavioral therapy.
Correspondence concerning this article should be addressed to:Lupu Viorel, Children and Adolescent Psychiatric Clinic, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania E-mail: firstname.lastname@example.org
Hysterical functional manifestations and hysterical personalities are characterized, as Cottraux (2003) said, by “a continuous show”, which consists of excessive emotional responses and constant attempts of attracting attention on themselves. Some traits, like reflection, self-control and systemization are little expressed, while expressiveness and exhibitionism are substantial, the world around being perceived as a “choir of admirers”.
According to Cottraux (2003), the fundamental belief of hysterical personalities is: “I have to impress the others or I am not worth anything”. In order to attain this imperative, the patient proceeds at dramatizing personal relations, has anger and crying crises and sometimes, suicidal attempts. The most important unconditioned postulates that describe hysterical personalities are: “I can’t bear to be bored”; “I want to be loved and admired”; “Only eccentric persons get attention”. The conditioned postulates and functioning rules of the same patients are: “In order to get what I desire I have to charm and amuse the others”; ”I must be an interesting person at all times”; “The others won’t love me unless I’m interesting”; “If the others believe I am special, they won’t notice my deficiencies”; “If I am in the mood for something, I must do that thing, whatever it takes” (Cottraux, 2003).
According to the WHO, ICD-10 classification, the diagnosis of dissociative disorders of movements and sensations involves perturbations of motor and intentional activity and perturbations of sensations that mime a neurological disorder, and the presence of the following features: there is no organic cause; symptoms may be correlated with a conflict situation; the patient needs special attention; the patient is hardly influenced by any kind of therapy; the displayed symptoms depend on the subject’s personal representations about his/her illness; the onset is acute, related to a psychological trauma; there is always a secondary benefit in manipulating the others and attracting attention toward himself/herself; it appears more often in young persons and may become a way of solving problems and stressful situations, representing an expression of personality; “la belle indifference” may be present; the patient may respond to psychotherapy and suggestion (placebo); the patient is highly suggestible, and may imitate symptoms displayed by people around him/her; manifestations may have a symbolic character (e.g. he/she paralyses for fear of not becoming aggressive), and may be associated with a low educational level and a high level of suggestibility; the prevalence is higher in certain families that suffer from this kind of disorder, while in the general population the prevalence is 10-25%.
Clinical manifestations are extremely variable and need to be distinguished from organically caused diseases, especially from neurological ones: “paralyses” (which can be complete or partial, do not correspond to the nerve distribution in the area and don’t respond to suggestion); ataxia; tremors, abnormal limb movements imitating tics; dysphonia, aphonia (hysterical akinetic mutism); vomiting; convulsions; anesthesia; pareses; loss of sense of seeing, hearing, diplopia (Georgescu, 1998).
A significant part of children and adolescents’ hysterical symptoms are effects of emotional trauma. After the trauma they become very sensitive to the adults’ reactions. Conversion disorder in adolescents debuts by the age of 12. Individuals affected are mostly girls (2/3 of the total number of cases). The most frequent manifestations of conversion disorder at this age are: psycho-motor agitation, somnambulism, astasia-abasia, paralyses, muscle spasms and vicious attitudes, enuresis, combined with tetany and/or epilepsy crises, as well as eating behavior disorders (Marie – Cardine & Collet, 1985).
Ajuriaguerra (1971) speaks about a true hysteria epidemic in girl boarding schools, and Lebovici (1985) asserts that, at this age, conversion disorder is often mistaken for mythomania and simulation.
Concerning the importance of hypnotherapy for conversion disorder, Patris (1985) believes that this technique leads to the disappearance of a hysterical symptom, which is quickly replaced by another. For this reason, it is useful to combine cognitive-behavioral techniques and suggestive techniques.
“Suzi” is a thirteen year-old adolescent. She lives in a Transylvanian town and she is a 5th grade studentl. “Suzi” has been hospitalized four times during the 1997-1998 at The Neuropsychiatric Clinic for Children and Adolescents. She presented polymorphic symptoms, which differed from one hospitalization to another: initially chronic vomiting, then intense headaches and opisthotonos crises, legs tremors and crying; functional facial paresis; non-kinetic mutism followed by language regression (language became childish) and hypotonic legs, respectively mutism with marked problems of walking and fainting crises.
The first hospitalization
The symptoms had appeared two years before the first hospitalization, with a chronic syndrome of vomiting that had been related to conflicts between her family and a neighboring family. Her case was investigated several times in Pediatric Clinics and she had been subjected to several medication treatments, but all these produced no noticeable results.
On her first admittance to the Neuropsychiatric Clinic for Children and Adolescents (Cluj-Napoca) “Suzi” had the following symptoms: strong headaches localized in the frontal and occipital areas, opisthotonos crises ended in limb tremor and crying spells. The length of these critical functional manifestations varied from 10-15 minutes to 2 hours, depending on how many people were present at the time of crises. More people surrounding her produced longer crises. Crises were not present when she slept. Neurological investigations and EEG indicated no pathological modifications. As a psychological type, her mother described “Suzi” as sensitive, hyperemotional, emotionally unstable, anxious, impressionable, and loving to be the center of attention. The psychological investigation revealed that the girl had an IQ of 95, rich expressive language, good social adaptability, low frustration tolerance, egocentrism, a desire to make a good impression and to be the center of attention, high suggestibility and histrionic characteristics. Her school results were very good. She was the first in her class in the elementary school. She also won an international mathematics contest and the prize consisted of a trip to Paris.
At the moment of her hospitalization, she completed the HADS anxiety questionnaire. Her score was 18 (a value higher than 11, which is considered pathological). Considering the psychogenic context described above and the absence of a somatic cause, the diagnosis according to DSM-IV was conversion disorder and according to ICD-10, dissociative disorder of movements and sensations, appearing in a conflict situation, based on a developing personality with sensitive and histrionic features.
At the time of the first hospitalization we initially resorted to supportive psychotherapy, followed by relaxation therapy, hypnosis and self-hypnosis. During the critical manifestations we resorted to suggestive psychotherapy (combined with the use of a chemical agent). This kind of psychotherapy proceeded as follows: at the time of her first “crisis” in hospital the patient was administered six under skin punctures in the navel area and one at the level of the nape, with distilled water as placebo, accompanied by verbal suggestions such as “you will feel a great pain with every shot, but don’t worry, the greater the pain, the better the effect of the medicine … then you will have a sensation of heat around the spot of the shot, which will then spread and block the area that leads to the unleashing of your crises, and of your head aches”. After this intervention the crisis yielded in 5 minutes.
At the time of the next “crisis”, only 2 punctures in the navel area and one at nape level were enough to obtain the same result.
When the third “crisis” occurred, just showing “Suzi” the syringe with the special medicine had the expected result, and at the time of the fourth critical manifestation it was sufficient to show the syringe needle for the crisis to cease. Then “Suzi”’s mother was given a syringe needle. She was instructed to show it to the girl whenever the “crises” appeared.
Outside the crises, hypnotherapy was used in order to diminish her anxiety and strengthen her Ego. She received a total of two hypnosis sessions, interspersed with self-hypnosis exercises, learned by the girl during hetero-hypnosis. During the first session, hypnosis induction was performed using the method of progressive muscular relaxation (Jacobson) and the deepening of trance was achieved through counting from 0 to 20. In order to diminish her anxiety, a variation of the “exercise of the blackboard” was used: “Imagine a blackboard on which you are writing with a white chalk the letter A, contemplate it and you grow calm, then you take a sponge and easily erase the letter, and you relax more…. and more… and more… Then you write the letter B… etc. (and proceed the same way with C and D). She was then told to continue with the next letters, starting with E, and to get more and more relaxed with each letter written and especially erased… After approximately 5 minutes, she was told to erase to blackboard with the sponge, to take the chalk in her hand and write down the following words, one under the other:
to contemplate them, and then to erase them easily…, easily… with the sponge and to grow more and more calm. Then she was suggested to take the chalk in her hand again and put down, one under the other, the following words that would remain on the blackboard forever:
WITH GOD’S HELP I WILL SUCCEED, I WILL SUCCEED…
I WILL SUCCEED
„You will do this exercise everyday, which will help you solve your problems.”
After that, she came out of trance by counting from 1 to 10. Then we administered the HADS test again, and obtained a score of 8 for anxiety (compared to 18 at the time of hospitalization). “Suzi” was explained that her critical manifestations and her headaches related to her state of psychic strain and to her anxiety. We advised her to practice the self-hypnosis exercise of the blackboard during the next three days. We re-administered the HADS questionnaire, before the second hypnosis session that took place three days after the first one. The scores were even lower, reaching 4 for anxiety.
During the second hypnosis session we placed a special emphasis on Ego strengthening suggestions, using the “river” and “oak tree” metaphors, adapted after Hawkins (1994) – (see Lupu, 2003). Also, she was directly suggested that every passing day she would become stronger and stronger, more and more confident, more and more independent, and that she would be of great help to her mother; consequently, her anxiety would diminish even more until it would gradually disappear…and so would the crises. When the girl came out of the trance, we administered the HADS questionnaire once again, obtaining a score of 2 for anxiety. She was advised to continue the “blackboard exercise” during the next 5 days until her leaving the hospital and then for 3 more weeks at home. At the time she left the hospital, “Suzi’s” anxiety reached a score of one. There were no opisthotonos crises, and her headache ceased completely. These results were maintained for 4 months, until the next hospitalization.
The second hospitalization took place 4 months after the first one. It was due to the onset of functional crises externalized through atypical right side facial paralysis that appeared on the basis of anxiety and subsequent hyperventilation. These symptoms had appeared a week before the second hospitalization, on the occasion of a more serious conflict between the girl’s family and the neighbors.
This time, cognitive-behavioral techniques were employed instead of navel area punctures. These were implemented according to the following scenario: The teenager was told about the relationship between the hyperventilation that appeared with anxiety exacerbation and facial paralysis. The therapist demonstrated how hyperventilation could be produced by breathing with the mouth open for 2 minutes. He highlighted the similarity between the girl’s sensations during hyperventilation and the anxiety experienced spontaneously during conflict situations. She then learned how to reduce her breath rate to 8-10 breaths/minute. Initially, the therapist set the breathing rhythm. The breathing had to be superficial, in order not to increase alkalosis, which could worsen the symptoms. Eventually, the patient hyperventilated herself voluntarily for 2 minutes, and then controlled herself rapidly using the procedure of reducing breathing frequency. Hyperventilation is more closely related to the depth of breathing than to its frequency. The patient was taught to breathe slowly and superficially, on the nose. The therapist showed her that facial paralysis that was created artificially through hyperventilation was similar to the one that appears spontaneous and involuntary, and that it disappears by breath control.
In order to eliminate facial paresis more rapidly, “Suzi” was taught vagal techniques, which are the fastest way to improve the symptoms. The simplest method consists of eliciting the Valsalva reflex. The patient was indicated to create an abdominal hyper pressure for 4 seconds, through forced expiration. The consequences were the fast decreasing of cardiac frequency, the appearance of a sensation of heat and spacing out breathings (4 seconds of blocking, followed by a 4 seconds expiration). During the first therapy session, this technique was repeated 12 times, until it was well learned by the patient. During another session, this technique was combined with imaginary exposure, during hypnotic trance, in order to reduce anxiety elicited by images of her family’s conflict with the neighbors. During trance the therapist also employed Ego strengthening exercises, through evoking locations from Paris (Montmartre, Champs-Elysee, Tour Eiffel, etc.), the patient had visited one year ago, as a prize for winning the international mathematics contest. She was given direct suggestions for gradual improvement of the symptoms and for getting well. Her homework consisted of: exercising the 3 steps breathing technique, and applying the “blackboard method”. The evolution was good from the moment the patient learned how to control her crises voluntarily.
The third hospitalization
The next hospitalization came 6 weeks after the previous one. The reason was the onset of non-kinetic mutism episodes, followed by language regression (it had become puerile), strong pain in the legs, hypotonic legs and slow falling, without losing consciousness or getting hurt. The therapy was very similar to the one implemented during the second hospitalization. The patient’s evolution was good. The symptoms disappeared after 14 days of therapy.
The last hospitalization took place two months after the previous one. Its motives were: reappearance of the mutism accompanied by a choking sensation, strong lower limb pain, especially in the thigh area, walking disorders (the girl stepped on the exterior side of her insteps) and also fainting crises. All these symptoms had appeared within the same conflict situation with the neighbors.
During hospitalization, therapy was used only under hypnosis, in 5 sessions, interspersed with self-hypnosis sessions. We are presenting an excerpt of one of these hypnosis sessions, when the “rainbow exercise” was associated with the TV technique:
Therapist: “Please take your shoes off and walk to the door of the office. Then come back. I notice that you walk in a particular manner; you step on the exterior side of your instep. Are your legs hurting?”
Patient: “Yes. Very badly”
T: “Do you remember having had this kind of problems last time you were in hospital?”
P: “Yes, but it wasn’t this bad.”
T: “All right…Now please sit down …Imagine yourself sitting in a comfortable armchair…in front of you there is a color TV…, you have the remote in your hand… You push the channel 1 button… and you see red color… on the screen you see a field of poppies that delights you … Then you press the channel 2 button… orange appears… on the screen you see a basket full of fresh oranges… you can see their green stalks … you smell them, and they smell nice… you look covetously at them, thinking of their flavored sweet-sour taste… You press the channel 3 button and see yellow color on the screen… then you see a mellow grain field… it is the end of July and it’s very hot… but there is a breath of wind that makes the grain bend easily and describe concentrical circles which unfurl closer and closer… and, as they unfurl… you grow more and more… calm… Then you press the channel 4 button and see… green color… you notice the green soft grass near the grain field… which invites you to sit down… and you sprawl in the lukewarm grass… it is soft like moss… and standing in the grass you feel a nice torpor in all your body… Then you press the channel 5 button and blue color appears…standing in the grass, you look through your eyelashes… a blue sky with no clouds, that quiets you more and more… you grow more and more calm, more and more relaxed…Imagine that you’re raising from the grass and next to you, you see a still lake that reflects the blue and clear sky, the lake reflects you too, like you would like to be: healthy, beautiful, walking without problems…your legs are recovering completely, completely, completely… Imagine that you can walk without any problems and repeat this to yourself: I WILL SUCCEED, I WILL SUCCEED, I WILL SUCCEED…With every passing day I will walk better and better and better… Your legs are recovering completely…You are calm and relaxed…Now please stand up and walk right to the door and back. It is much better! Do you notice?”
T: “Please sit down and tell me what is it that you’ve felt?”
P: “I felt a nice heat in my legs and I haven’t felt pain so I could walk better”.
T: “Please stand up again and jump to the door on one leg, then come back jumping on the other leg. Do you notice how well you can do this? ”
T: “Now please sit down and relax. You are calm and relaxed. With every passing day you will walk better and better, you will breath easier and easier. Now you’re in front of that TV again, press the channel 6 button and you see indigo color, with violet reflections… you see the sky at the horizon, right after the sunset… you are calm and relaxed… old people in villages say that when this color appears, the next day will be a nice and clear day…”
When “Suzi” recovered from the trance, her walking improved a lot. She was given the following homework: to practice the rainbow exercise, combined with the TV technique each night before going to bed; these were supposed to be preceded by 3 series of 3 steps breathing.
She was also advised to practice 3 steps breathing every time she felt pain in her legs that caused walking difficulties or every time she felt she could not breathe or that she would faint. The evolution was good; symptoms remitted completely in ten days, and have not reappeared for two years following the fourth hospitalization.
To conclude, psychotherapy proved effective in this case of conversion disorder with mixed presentation in a 13-year old teenager. In this case, medication yielded no results. Consequently, we can say that psychotherapy is a valuable therapeutic alternative for conversion disorders, which appear relatively often in children and adolescents.
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