disc 8

Lecture: Somatoform and Dissociative Disorders READING: CHAPTER 8 http://www.mayoclinic.org/home/ovc-20269555Links to an external site.

http://emedicine.medscape.com/article/918628-overviewLinks to an external site.

 

Keeping you on track!

1. Read Chapter 8 from Textbook.

2. Read Sims’s Chapter 15 and Fernandez’s “You are the Chief” (see below) and “My brother’s keeper” pgs 173-176 (an interesting case of conversion disorder).

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First of all, thank you so much for your comments and class participation. This class has done an excellent job at responding and thinking about the topics we have discussed so far. I am very happy with your efforts, thank you! Also, I appreciate you are happy with the reviews. It is a pleasure, and I want you all to be successful in this class.

By the way, as I was cleaning my papers and emptying closets, I ran across the “certificate” my phobia patient made for me. I thought I had lost it, and wow! I found it again, and I thought it would be great to show it to you. This is the girl from the Rotten Teeth story 😊 I have included it as an attachment.

In terms of success in this class, I need you to be mindful of the following:

1. If you did not get the grade you wanted or you failed to take the exam for whatever reason, remember you can drop a Test grade, so no major harm has been done…yet. This is your opportunity to turn this thing around.

2. Overall grades have been very good, and that is a good encouraging sign!

3. Finally, as I have said before, keep mindful of deadlines, login frequently, participate (answering all my posts and some of other student’s as well, please see Syllabus), study as you go along (not the night before), do the topic review and do not wait for the last minute to take your test!

OK, back to the topic at hand. This week’s topic is also interesting and one responsible for the birth of Psychotherapy as a modern, professional activity; that is Freud’s interest in Hysteria and his method of Psychoanalyses opened a new world for all of us. I hope you like it.

This is the story about a Conversion Disorder patient I treated a few years ago. The other case, not included here (My brother’s keeper) is also one of my favorites and if you got the book, read it; it is very interesting as well. I hope this continues to be useful to you guys.

Have a great week…Enjoy it!

 

Class Participation

You are the Chief

 

Saturday night in southern Spain is an absolute delight. The Andalusians love the Café-culture, and for good reason. You meet friends and neighbors, make new acquaintances, discuss the latest political gossip over a cup of coffee or while enjoying good Cherry wine or Rioja. They love to dance their Sevillanas in their local Bars and Cafes and they do this spontaneously, celebrating their culture and truly savoring life at its best. Even when nothing seems to be happening, they do best what the French call “Voir et etre vu” (to see and being seen). The atmosphere is always very festive and one gets easily caught-up in the ambience of this culture. 

One summer night, while I was strolling with friends and family along the beautiful promenade of the little coastal town of Rota, Cadiz, I received a call from the ER doctor working at the nearby Naval Hospital. I was the Mental Health doctor on call that weekend. Needless to say, I was not too happy to get the call, but things got worse for me when I heard he wanted me to come in an evaluate a patient who did not seem very appropriate for Mental Health. Typically our calls involved cases of suicidal ideation or attempts, out of control individuals or psychotic patients. This one was different. The patient was a man in his thirties who for the last 6 weeks or so was having fainting spells followed by numbness in his extremities. He would always recuperate within hours of the event with no apparent consequences. He had been previously healthy. He had undergone significant evaluations and all medical tests, including radiographic studies and neurological assessments had been normal. This particular Saturday night, while fixing a light at his home, he had had another fainting spell, falling off the ladder he was on, and getting a couple of minor superficial cuts and bumps on his arm, shoulder and head. His wife had brought him to the ER, and the doctor did not know what to do for him, so he thought Mental Health could help.

When I arrived to the ER, I was directed to the patient’s bedside. There he was talking very animated with his wife and he did not appear to be in any kind of distress. I introduced myself and told him the purpose of my visit. I mentioned to him the ER doctor felt I could perhaps help trying to understand the role of “stress” in his current life and the possible link between stress and his fainting episodes. He was very pleasant and cooperative but seemed “baffled” by his symptoms.

P- Doc I have no idea why I am having these fainting spells. I know they have done all kinds of tests and everything to this point has been negative. I don’t understand it.

I explained to him we are not taking any symptom lightly and we would continue to seek the cause for his problems. At the time I was still concerned regarding his symptoms and I was not going to jump in the “it is all in your head” wagon. I then proceed to ask him questions regarding his current life situation, his job, his marital relationship, his own level of perceived stress. I also asked his permission to talk to his wife in private, which he gave me without hesitation. Everything however, seemed to be fairly normal. They were very happy in their marriage. He did not have any significant financial problems or worries of any kind. He did not have alcohol, drugs of gambling problems. He was doing excellently at his job, so much so that he was being promoted to Chief Petty Officer in the Navy. This is a major promotion for enlisted men in the Navy, not only in terms of the actual increased in salary associated with the promotion, but because of its significance. Chiefs in the Navy have a special status. They are seen as the backbone of the Navy; they have “all the answers” and provide guidance and support to enlisted sailors and officers alike. They begin to wear uniforms which are very similar to the ones officers wear and they are held, and rightly so, at very high esteem. Few are able to reach this rank, and for those who are selected for Chiefs, their lives are completely transformed. This transition from regular Petty Officer to Chief Petty Officer is marked by a process which is called the “chief’s Initiation” which involves several weeks of intensive training, community service, and rigorous physical exercise which culminates with a very special promotion ceremony. This patient was going through this process when his symptoms began.  At this junction I figured that if anything “psychological” was connected to his symptoms, it had to be his promotion to Chief Petty Officer.

As I continued to talk to him, the latest round of tests done in the ER came back, and as before, everything was “normal”. He rolled his eyes with an expression of disgust and said:

P- You see Doc, it is always like that, but I can tell you I am not making this s**t up. I feel very frustrated!

T- I understand and I wish I could help you, but I am not sure how we could do this. I suspect your initiation is creating some level of stress on you and in some ways, it is related to your symptoms, assuming there is a relationship. Does anything ring a bell?

P- Nothing, I am in good shape other than these fainting spells, so I do not find this initiation particularly difficult. I am very happy for the promotion and excited about becoming a Chief.

 

At this point, I was getting ready to tell the ER doctor that I was going to schedule a follow up with the patient in the regular outpatient clinic, and I did not have anything else to offer at this time. Similar to the other medical tests, the psychological evaluation did not show any areas of concerns. My thought was that perhaps “stress” was related, but I had nothing to base it on. Yet, it seemed we had made a connection and since I was already there and my Saturday evening was gone, I offered we talk for a while. I told him I wanted to get to know him better and his background. He told me about his military career, meeting his wife, wanting to go “as far as he could” in the Navy and then have the best life with his wife and future family. As he talked I felt he never told me about any particular painful memory or event in his life. Then I suggested the following:

T-Listen, I would like to do something with you that sometimes helps in connecting the present with the past, and usually helps making sense of what is going on with our lives. I would like to do a relaxation induction (hypnotic induction) first then I would like to ask you some more questions.

 

The patient did not have any objections to do so and I proceeded to do a deep breathing exercise followed by an eye fixation induction that lasted a few minutes. I had asked him to tell me when he felt very relaxed so we could continue. When he told me he felt deeply relaxed I said:

T- John I would like for you to remain relaxed and comfortable and at any time you feel anxious or uncomfortable, you need to tell me, OK?

P- Yes, Doc.

T- OK, then. John I would like you to think of your current life situation, what is going on right now that may be related to your symptoms, and that in some ways may be related to some other experience from your life. Specifically, I would like for you to focus on how you feel, could you remember any event or time in your life which may be emotionally related to your present?

P- (Long pause)…Doc this may not make any sense at all, but I do remember something.

T- Don’t worry about not making sense, go ahead.

P-This was after my father’s death. Those were very difficult times for our family. I was the oldest boy and my mother was very sad and desperate. We did not have much of a financial situation at the time.

T- I can imagine how hard this must have been for your mother and even for you.

P- Yes, it was.

T- Do you remember anything in particular about that situation?

P- Lots of sadness and fear.

T-You felt sad and fearful?

P-Yes

T- Could you tell me more about it? What was particularly fearful for you?

P-One day when we were alone in the house, my mother and I, she was crying and I approached her to console her. She embraced me and looking at me she said “John you are now the man of the house, the Chief of the household.

T-John, I don’t want to jump to any conclusions here, but would the “chief of the household” have anything to do with becoming Chief in the Navy?

P- I don’t know Doc.

There was no momentous catharsis, the burst through of repressed emotions or memories or any change in his expression or demeanor. This was said the same way he had said everything else. He felt he always had the memory, just “didn’t think of it”

We then continue to talk for a few more minutes clarifying those memories and the feelings associated with them. When we finished, I told him I wanted to continue to see him in the outpatient clinic. I told him that I was going to request that he be excused from finishing this initiation as I felt the process was increasing his anxiety and producing the symptoms. We need to talk more about this transition phase in his life and the fears it was generating.

The patient was very compliant, but the Chief’s Community was not very happy as I was “obstructing” tradition. After a little bit of a power struggle, they agreed to allow him to do a modified initiation, which he completed without any problems. 

We began to work in outpatient psychotherapy seeing each other 2-3 times per week. I encouraged him to talk about his fears and concerns, about how difficult it was for a young child to “become the chief of the household” and how difficult may feel to him to become “the Chief in the Navy”. I also encouraged him to practice general relaxation training and to see his job as a Chief in more “down to earth” perspective. He did not have to be “superman”, but continue to be the good sailor he had been. In other words, we tried to develop a new conception of his role and his actions; a new way of “seeing himself” vis-à-vis his relation to others in the job he was now called to do. He did well. Most importantly, in the weeks to follow, including the day of the actual promotion, he did not experience any fainting spells. In fact, for several months until he moved on to another assignment and left, he never had any other fainting spells. They had gone forever.

This patient presentation and reported symptoms are consistent with the diagnosis of Conversion Disorder or as it was once known, Hysteria. This condition has a long and interesting story. By late 19th century a great number of patients were exhibiting a wide range of neurological-like symptoms which included paralysis, blindness, convulsions, loss of ability for speech or hearing and other similar problems, but without any physical findings that would lend support to an organic cause for the symptoms. Most of the patients who suffer of these symptoms were females. In antiquity it was believed that the uterus (Hysterus) was responsible for that condition, and so it was automatically assumed only females suffered from it. Some of these patients became very famous due to the complexity and dramatic nature of their symptoms. One of the leading neurologists of the time Charcot was particularly interested in this condition. He was a very flamboyant individual who engaged his Hysteric patients in public demonstrations of this condition creating a true sensation in professional and non-professional circles alike. His patients became famous and people came from all over Europe to see his demonstrations and meet his patients. Among those who came to Paris was a young physician from Vienna called Sigmund Freud. This is the disorder that compelled Freud to seek an explanation outside the prevailing notions of his age into one that accounted for particular meanings, desires, hopes and fears. He ventured into the human spirit and our well-known human ambivalence of desiring and rejecting, fearing and loving, accepting and denying. In the process, he opened a new way of seeing man and understanding human suffering. He had the insight of the “psychological” bases for hysteria, which he related to repressed sexual impulses; the great Taboo of his age.  As time went by, changes in social norms and mores, in physician expectations and in the social reward associated with attention, made hysteria cases rare, even to our times.

This phenomenon of Hysteria, the “transformation” (conversion) of psychological conflicts into physical symptoms is however well and alive today, but not in the classical form as Freud knew it. The presentation has changed, as patients, society and our level of scientific and medical knowledge has changed from that of the 19th century. Beyond the clinical idea of hysteria as “conversion of psychological conflicts into physical symptoms”; it is also “expression” and communication. The patient is both expressing certain psychological dilemma or conflict and communicating it to others via in physical symptoms. Therefore, the symptoms are a communication medium for the patient as well as a way to express the inner conflict. The symptoms as Freud pointed out may be a “Symbolic” representation of the conflict, but may not always be the case. For example my patient “fainting spells” may be a symbolic representation of his desire “not to face, ignore or avoid” becoming a Chief, but other cases I have known have had less clear connection.  The other important aspect of this condition is the idea of conflicts “as repressed”, meaning the content of the conflict has been pushed back in the person’s unconscious, literally outside the person’s awareness. Here again, I am less convinced of this mechanism. Yes, patients do act and behave in ways that are clearly oblivious to the reason for their symptoms, but then we run into other difficulties. This amounts to self-deception, and as Sartre argued many years ago, self-deception is self-contradiction. There has to me a part of “me” who is aware of the conflict within “me”. It is me deceiving me, lying to myself, but not acknowledging it all at the same time! Finally, it is important to observe that there is a significant level of personal reward patients achieve from his symptoms. Freud called it “secondary gains” and behaviorists in our time have identified as positive reinforcements. Essentially, people with those kinds of symptoms tend to get significant attention, medical benefits and the social benefit of not having to perform certain social commitments…because they are ill.

In the present case with my patient, I gave him the opportunity to express his fears (which he never hinted were outside his awareness), offered understanding and support and gave him a plausible explanation why that was occurring to him, and how he could benefit from it . .By requesting that he be allowed to be promoted to Chief without going through the “initiation”, I gained time to work with him and helped him achieve the goal of “avoidance” without having to use his symptoms. At the end, he was promoted, with a new conceptualization of what it meant to him, and as far as I know, he was able to work without any further problems.

 

HERE IS THE CERTIFICATE!  SHE HAD A GREAT SENSE OF HUMOR