Communications that place patients in a double bind about maintenance of conversion symptoms have been described. One such technique is to suggest to a patient who has a strong relationship with his or her therapist that failure to improve may have negative effects on the therapist’s career (Neeleman and Mann 1993). As a result, the patient must improve or damage someone for whom he or she has concern and affection.

Another manipulative ploy is to tell a patient that there is a question as to whether the etiology of the symptom is psychogenic or physical (Teasell and Shapiro 1994). The patient is informed that failure to respond to a specified treatment will indicate that the symptom is psychogenic in etiology. Thereby, the patient is placed in a bind in that maintenance of the symptoms indicates a psychological cause.

Both of the above techniques create ethical concerns because they involve deceptive communications to the patient.

Hypnosis

Patients with conversion disorder have above-average hypnotizability; in fact, conversion symptoms and those induced by hypnosis are similar (Van Dyck and Hoogduin 1989). These phenomenological observations, which date back to the 18th century (Makari 1994), have led to the use of hypnosis as a treatment for conversion symptoms. Although no controlled studies of hypnosis as a treatment for conversion exist, many case reports suggest that this technique is efficacious. The introduction of an altered state of consciousness through hypnotic techniques may allow the patient to relax his or her defenses and provide information about the precipitating event or psychological conflict (Swartz and McCracken 1986). Function of the affected organ may be restored through suggestion and by posthypnotically suggesting that the symptom be discarded. Similarly, there can be a suggestion that information obtained during the hypnotic stance will be remembered when the patient awakes. Hypnosis is generally provided as part of a comprehensive treatment plan (Hoogduin et al. 1993; Moene et al. 1998).

Amobarbital-Assisted Interviews

An altered state of consciousness can also be achieved by the use of intravenous medications. Amobarbital has been the traditional medication of choice, but lorazepam has been recommended as a safe, satisfactory substitute (Stevens 1991). The medication is injected slowly until evidence of intoxication is achieved. Ataxia, nystagmus, or numbers missed while counting backward are means to assess the onset of intoxication. Methylphenidate may be used to maintain wakefulness and facilitate verbal production. In this altered state of consciousness, the patient’s defenses, particularly repression, may relax and new historical information may be provided. There may be a return of function or partial function of the affected body part, and underlying affects such as depression may emerge. Caution must be exercised in that the procedure has the risk of exacerbating psychosis in a paranoid or schizophrenic patient (Hurwitz 1988).

Fackler et al. (1997) reported the use of serial amobarbital interviews in 21 patients with presumptive diagnosis of conversion disorder. These interviews provided complete or significant symptom relief in eight patients, reassignment to a different diagnosis in two patients, and attainment of meaningful additional psychosocial information in several patients. No adverse responses were described.

Details of the technique of amobarbital interviews have been provided by Iserson (1980), Perry and Jacobs (1982), and Soroglio (1984). Contraindications include noncooperative patients or patients with compromised respiratory or cardiac status, a history of allergy to barbiturates, or porphyria. An amobarbital interview is, in general, a benign procedure, but precautions for the rare risk of cardiorespiratory arrest must be made. Laryngospasm is the most common serious complication. Equipment for cardiorespiratory resuscitation must be readily available before starting the procedure.

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Charles V. Ford, M.D.
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Full References