Reassurance and Suggestion

Reassurance and suggestion is one of the most important therapies provided by physicians (Kathol 1997). To be effective, it must be preceded by an examination of the patient and assurance that serious disease is not present. This approach may play a primary therapeutic role in acute conversion symptoms and prevent reinforcement that may perpetuate the symptom into a chronic disorder. Reassurance and suggestion is particularly effective as used by primary care physicians, including pediatricians (Zeharia et al. 1999). It must be reemphasized that each conversion symptom, even if there is rapid remission, must be investigated because of the possibility of hidden environmental stresses and/or underlying psychiatric or neurological disease.

Psychotherapy

Despite the important role that the treatment of conversion symptoms played in the development of psychoanalysis, insight-oriented psychotherapy usually has a limited role with conversion patients. These patients tend not to be psychologically minded and do not have the motivation or financial resources to pursue such treatment. An understanding of unconscious processes and the use of psychodynamic formulations in the development of treatment plans are, however, immensely valuable.

Occasionally, a patient will respond to a direct interpretation. Ford (1983) reported on a patient, already engaged in psychodynamic therapy, who developed a conversion paraplegia during the therapist’s vacation. On his return, the therapist saw her briefly during her hospitalization in a medical-surgical service. The therapist made the interpretation that the patient felt that she could not “stand on her own two feet” during his absence. She was also gently told that she was expected to keep her next outpatient appointment as scheduled 5 days later. She kept her appointment, and, with the resumption of psychotherapy, transference issues that included dependency wishes and anger at her perceived abandonment by the therapist were addressed. The conversion was interpreted and worked through as a manifestation of transference within a therapeutic relationship.

At times, brief psychodynamic therapy can be remarkably successful and cost-effective in the treatment of conversion disorder. Viederman (1995) reported the case of a 68-year-old man who responded to direct interventions that involved both the interpretation of unconscious motivations and suggestions that were made with conviction and authority. The therapy, which consisted of six sessions, was marked by symptom relief during the first session and consolidation of therapeutic gains during the following five sessions. The primary technique used during the consolidation portion of therapy was the psychodynamic life narrative, which showed the patient the logic of his symptom as a product of his life experience.

More frequently, the psychiatrist will choose not to deal with conversion symptoms in a direct way in an effort to avoid resistance and consequently make the patient adhere more rigidly to the symptom. Patients may accept interpretation of their symptoms as stress responses if the clinician does not directly imply that the symptoms are “all in the head.” Through nonconfrontational supportive psychotherapy, the therapist may facilitate catharsis, encourage a more open expression of repressed affects, allow mourning to proceed, make directive comments, or promote problem solving. The therapist may use suggestion to indicate that the symptom is benign and will resolve with the concurrent help of physiotherapy, biofeedback, and so on. These face-saving techniques may be essential to allowing the patient to discard the symptom with dignity.

Family psychotherapy may be necessary when a symptom is reinforced by other family members as a way of diverting attention away from family conflicts. For example, one family conflicted because of anger over family secrets, which included substance abuse and sexual acting out, rallied around the identified patient who had developed a psychogenic aphonia. Concern about their teenage daughter—the patient—brought the parents together. A change in family dynamics was required for the patient’s symptom to remit. Family therapy may play an important role in the treatment of children or adolescents who present with conversion symptoms (Griffith et al. 1998; Turgay 1990). The types of family structure and dynamics that promote somatic symptoms in a child were outlined by Minuchin et al. (1975) and include issues such as enmeshment, overprotectiveness, rigidity, and lack of conflict resolution.

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Charles V. Ford, M.D.
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Full References