Behavioural interventions in the rehabilitation of acute v. chronic non-organic (conversion/factitious) motor disorders
Shapiro AP and Teasell RB;
Commented by , 23 Aug 2004
Background
While multidisciplinary inpatient behavioural treatment (BT) programs have shown promise in the treatment of acute non-organic motor disorders, chronic disorders may be refractory to such interventions.
Purpose
To examine the relative efficacy of standard vs. strategic BT with acute vs. chronic non-organic motor disorders.
Methods
Repeated case study of 39 consecutive patients (82% female) admitted to a canadian tertairy care rehabilitation unit between 1987-1998, with an established diagnosis of non-organic motor disorder. 9 patients had an "acute" (onset < 2 months), and 30 had a "chronic" (> 6 months) disorder. The primary symptoms were limb paresis/paralysis (79%), astasia/abasia ("ataxia with a bizarre lack of coordination"; 31%).
All patients underwent a standard BT program. Using a crossover design, patients who failed to improve after 4 weeks underwent strategic BT. Outcomes were determined by retrospective chart reviews by both authors, with complete recovery defined as no overt signs of abnormal movement or posture suggestive of disability.
In standard BT, patients were informed that irrespective of etiology, symptoms were maintained by abnormal muscle patterns developed over time, with treatment aimed at re-learning proper muscle functioning. Daily physiotherapy involved progressive gait and posture re-training with positive reinforcement through praise.
The central distinction of the strategic BT was telling patients and families at several junctures that full recovery established evidence of an organic etiology, whereas failure to recover provided conclusive evidence of a psychiatric (conversion) disorder, with the "unconscious need to remain disabled." For the latter condition, long-term psychiatric treatment was available. Otherwise, the program was similar to standard BT.
Results
Standard BT led to complete recovery in 8/9 "acute" patients compared with 1/28 "chronic" patients. Of the 22 patients who then underwent strategic BT, 14 acheived complete recovery at discharge.
Individual counselling targeting coping skills was offered to the first 20 patients, based on the theory that deficient stress modulation is central to conversion disorder. The majority, however, denied emotional concerns and failed to engage. Thus, counselling was removed. All patients either declined or failed to attend follow-up counselling.
Discussion
While the repeated case study design has its limitations, it is a useful approach to such populations difficult to recruit in large numbers. In this study, it took the authors 11 years to study 39 patients. Were large randomized controlled trials the standard for all populations, we would stand to gain few insights about treatment for this complex group of patients.
The results of this study raise intriguing questions. Is a relatively simple, face-saving, behavioural program the approach to this treatment-refractory and costly population (ref. 1)? Are psychological treatments designed to gain insights into unconscious conflicts or family systems dynamics unnecessary or countertherapeutic? Are therapies targeting stress management unwarranted? Perhaps, although in the absence of control and longitudinal data, these questions remain unanswered.
As the authors note, conversion disorder has a fluctuating course, and improvements may have reflected the natural course of the illness. The assumption that this acute intervention would translate into sustained gains for this treatment-resistant and chronic population (ref. 1) would be naïve. In the authors' attempts to follow the first 20 patients, they estimated a 30-40% relapse rate, underscoring the need for maintenance and complementary treatment for this vulnerable patient group.
Finally, the authors provide a provocative discussion on the ethical considerations of their strategic approach, beyond the scope of this forum, but certainly fodder for any ethics review board.
References
Mace CJ, Trimble MR. Ten-year prognosis of conversion disorder. British Journal of Psychiatry 1996;169:282-288