Behavior Therapy - Conversion Disorder and Somatoform Disorder Not Otherwise Specified

Behavioral modification is frequently used in the treatment of conversion, even when the therapist may not be deliberately or consciously employing it as a specific technique. Praise and encouragement for improvement can be viewed as positive reinforcers, and ignoring the sick role behavior may facilitate its extinction (Alford et al. 1972; Mumford 1978).

Systematic, well-controlled studies of behavior therapy are very limited, yet many authors have reported on series or single cases indicating successes with this treatment approach. Techniques described by these authors are relatively simple. Direct instruction and suggestion may be followed by increasingly "expensive" praise; in other words, to maintain the praise and approval, the patient must make increasingly greater increases in improvement (Agras et al. 1972; Hersen et al. 1972). Operant conditioning may be used in the form of rewards for improvement (e.g., increased privileges, home visits for inpatients) (Dickes 1974; Gooch et al. 1997). Concurrent with this technique, failures and symptomatic behavior may be ignored.

Behavior therapy is most often combined with physical therapy (see section "Somatic Therapies" later in this chapter) and associated therapies (e.g., speech therapy) so that improvement can be measured in specified increments.

For example, Mizes (1985) described the treatment of a 13-year-old girl whose symptoms were the inability to bend at the waist and the inability to move her torso. Her muscle activity was monitored via an oscilloscope display of electromyographic activity. These biofeedback sessions were associated with contingency reinforcement (rewards). If the patient met target behaviors (e.g., a specified degree of muscular contraction), she was granted increased parental visiting time for a given day. This combination of techniques led to significant improvement.

Blanchard and Hersen (1976) observed that symptom relief can be achieved by extinction and contingency reinforcement. However, they noted that symptoms are likely to return if the behavioral modification program is not continued at home and if the patient does not learn new ways to communicate with the social environment.

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Behavior therapy, in conjunction with physical therapy and other adjuvant therapies, may be best provided on a rehabilitation unit (Speed 1996; Teasell and Shapiro 1994; Watanabe et al. 1998).

Speed (1996) described successful outcomes for a majority of patients by using the following treatment protocol and therapeutic principles:

1. Completion of diagnostic tests prior to admission for behavioral treatment
2. No mention of conversion disorder by any staff member; rather, the referring physician provides a partial explanation that test results have been normal but that messages from the brain to the muscles are not being transmitted in a normal fashion and that therapy can restore function3. Coordination of treatment by the attending physician who clarifies questions or uncertainties about management and resolves conflicts among the treatment team4. Continuity of nurses and therapists to the maximum extent possible5. Avoidance of negative or hopeless statements6. Videotaping of the patient's function before starting physical therapy/occupational therapy and just before discharge7. Use of physical therapy with a structured progressive program to increase function and mastery of each step before moving on to the next8. Use of occupational therapy with a structured step-by-step program in a manner similar to physical therapy9. Rest of affected body part(s) when not in therapy (e.g., use of wheelchair for lower-extremity symptoms)10. Provision of psychotherapy and stress management classes on a case-by-case basis, if indicated11. Minimal use of passes or outings; these are to be used for reinforcement of significant functional improvements in treatment program