Treatments that include some manipulation of the body or its functions have been suggested for conversion disorder. These adjunctive therapies have proven to be invaluable contributions to a comprehensive treatment plan.

Pharmacotherapy Pharmacotherapy is primarily indicated for the depressed patient with conversion symptoms. A full discussion of pharmacotherapy for depression is provided in Chapter 47 of this volume.

Electroconvulsive therapy Electroconvulsive therapy (ECT) has been reported to be effective in some patients with conversion symptoms (Cybulska 1997). This is probably because ECT is an effective treatment for underlying depression, but ECT also may have a direct effect on cortical inhibition, memory, or both (Merskey 1989). The response also may be attributable to the placebo effect of a dramatic treatment.

Physical therapy Physical therapy plays an important, perhaps essential, role in the treatment of a variety of paralyses or gait disturbances. The physical therapist provides encouragement, reassurance, and reinforcement for improvements (Delargy et al. 1986; Keane 1989; MacKinnon 1984). Furthermore, physical therapy prevents, and sometimes treats, disuse atrophy. Physical therapy tends to legitimize the sick role and provide a face-saving mechanism for recovery (Lazarus 1990). On the other side of the coin, legitimizing the sick role can be a reinforcer for maintenance of the symptom, particularly if the patient perceives the therapist as providing attention (nurturance) not easily obtained elsewhere.

Biofeedback Biofeedback allows a patient to have concrete evidence of the intact physiological functioning of the disabled body part. Intact sensory organs and innervation can be demonstrated through evoked potentials, and muscle activity can be demonstrated via electromyography (Fishbain et al. 1988; Klonoff and Moore 1986; MacLeod and Hemsley 1985). Furthermore, the use of biofeedback allows for measurable physiological activity that can be used within a behavioral modification treatment plan (Klonoff and Moore 1986). A unique treatment strategy used by Jellinek et al. (1992) was a transcranial magnetic stimulator that created motor-evoked potentials and involuntary leg muscle contractions in a patient with a conversion paraplegia. The patient was able to witness his leg contractions, and his conviction of physiological preservation was reinforced by viewing his motor-evoked potentials on the display of the recording equipment. He had a complete recovery a week after this treatment.

Faradic stimulation Faradic stimulation is the stimulation of skin and underlying structure with a low-amperage electrical current. It has been used since the beginning of the 20th century. The sensations created, when mild, may provide a placebo effect. When the current is increased, the shocks may be used for aversive conditioning (but this is not recommended). Hafeiz (1980) found faradic stimulation to be as effective as other treatment modalities when used to treat acute conversion symptoms in unsophisticated patients. Pu et al. (1986) also used electrical stimulation in selected patients but preferred supportive therapy for most patients because they believed the latter promoted a better therapist-patient relationship.

Deeper stimulation of muscles elicits muscular contractions. Such stimulation may prevent disuse atrophy and be a potent suggestion to the patient that function remains intact. This technique, in association with behavioral modification, was described by Khalil et al. (1988) as effective in treating conversion paralysis.

Speech therapy Speech therapy may benefit patients with symptoms of aphonia or vocal cord dysfunction, a disorder that mimics asthma (Christopher et al. 1983; Geist and Tallett 1990; Ophir et al. 1990; Thorpe et al. 1985). One technique used is an exercise that progressively increases the patient’s conscious control of vocal cord mobility. The speech therapist, much like the physical therapist, becomes the supportive person who reinforces symptomatic improvement and provides a face-saving mechanism for the patient to discard his or her symptom. Speech therapy for vocal cord conversion symptoms is generally provided in association with other treatment modalities, including family therapy, behavioral modification, and pharmacotherapy.

Environmental Intervention

The degree of environmental stress or psychological conflict that a patient experiences may be so irresolvable that the patient cannot realistically cope with the situation. A military recruit may be too immature to complete boot camp and may require removal from it; a sexually abused adolescent may require placement outside the home. Furthermore, at times, the physician must give permission (or instructions) for people to behave in certain ways. Caplan and Nadelson (1980b) described women who developed conversion symptoms in response to their feelings of being overwhelmed by responsibilities yet being unable to say no to demands. They termed this the Oklahoma complex, named after “the girl who couldn’t say no.” In such situations, the physician can make directive statements (i.e., issue doctor’s orders) to the patient, family, or both for the patient to reduce his or her activities.

Treatment Outcome and Prognosis

Most conversion symptoms remit fairly quickly, often spontaneously. The literature is replete with descriptions of rapid resolution of an acute symptom in response to suggestion, hypnosis, or an amobarbital-assisted interview. Factors related to a poorer prognosis include chronic symptoms (i.e., those lasting longer than 6 months), significant secondary gain (e.g., seeking a disability pension), and older age (Krull and Schifferdecker 1990; Mace and Trimble 1996; Teasell and Shapiro 1998). A good prognosis is associated with a symptom precipitated by a stressful event, good premorbid health, and absence of a comorbid neurological or psychiatric disorder (Lazare 1981). Symptoms in children and adolescents typically remit fairly quickly in response to treatment (Gold and Friedman 1995; Leslie 1988; Turgay 1990; Zeharia et al. 1999).

Symptom recurrence or symptom substitution occurs in a minority of patients but is sufficiently common to be of importance (Hafeiz 1980).

The long-term prognosis of conversion symptoms suggests that in a certain proportion of conversion patients, a significant underlying neurological or psychiatric illness will emerge. Follow-up studies done in the 1960s and 1970s suggested that a sizable number of patients would develop neurological or psychiatric disease to retrospectively explain conversion symptoms (Slater and Glithero 1965; Watson and Buranen 1979). Recent reports of follow-up investigations of conversion symptoms indicate a much lower incidence of previously unrecognized neurological or psychiatric disease (Binzer and Kullgren 1998; Crimlisk et al. 1998; Mace and Trimble 1996). As noted earlier in this chapter, in a few cases, covert disease may have facilitated development of a conversion symptom rather than the symptom being a direct expression of the neurological disease.

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Charles V. Ford, M.D.
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