I would encourage the patient to practice this approach 10 times a day, whether for a minute at a time or 5 minutes. I like to suggest that this problem does not magically disappear but would slowly resolve with the practice effect. It’s a good approach, which can help to save face, when treating certain psychological problems for which we do not know the cause.
The second visit, usually 2 weeks later, would be a reinforcement of the first visit and offer further discussions of the problem. The approach is clear, and after all the repetitions and suggestions are completed, so is the procedure.
A Case of Symptom Transference
One patient with conversion disorder I treated was a young woman who had moved from the Midwest to continue a business career in New York City. She developed a jerky right shoulder movement shortly after starting a new job that she wanted.
Knowing some of the work I do, her primary care physicians referred her to me purely for treatment of the symptom. After 6 months of dynamic psychotherapy, during which she discussed her separation from family and friends as well as the new job stressor – including a demanding chain of command at work and its symbolic representation to other aspects of her upbringing – she continued to have the movements.
This candidate was a good one for hypnosis but did not relate to the movie screen strategy. After discussing some of the issues that might have been at the root of the movement disorder, I tried a symptom transference approach. While she was in a hypnotic state, I encouraged her to focus on moving the middle finger of her right hand whenever the right shoulder jerked. The aim, as I clearly discussed with her, was to transfer the shoulder movement to the finger. An additional idea was that after she made this transference, she could use the finger movement to displace work stress and anxiety by moving the finger faster during stressful periods and or not at all during nonstressful periods.
It is also fairly true that a newly acquired movement is easier for a person to extinguish than a consolidated one and that, over time, the patient would gain greater control over her right middle finger than the uncontrolled shoulder movements.
The approach worked, and the shoulder movements stopped. As I understood it, she was able to keep the finger movements under good voluntary control.
Time and again the notion of symptom substitution arises. My experience and that of others who use hypnosis in symptom removal is that symptom substitution might occur in a few cases. As a general rule, however, those people who are motivated for the symptoms to be removed are successful and do not seem to show any further problems.
Helping the Patients in Le Roy
The National Institutes of Health is the process of recruiting participants for a prospective study that includes healthy volunteers and people with psychogenic movement disorders or nonepileptic seizures. Participants aged 18 years and older might be eligible for the study, which is being conducted at NIH and at Brown University Rhode Island Hospital in Providence.
The agency extended an invitation to the young people in Le Roy, but only one of those patients has been seen, according to Dr. Mark Hallett, a neurologist who serves as chief of the NIH’s Human Motor Control Section. He is also on the Editorial Advisory Board for Clinical Neurology News, a sister publication.
Nevertheless, Dr. Hallett said in an interview, many of the patients seem to be improving. "This is certainly good, and one of the factors might be the reduction in media interest," he said.
As research continues into the causes of conversion disorder, we psychiatrists must be prepared to help patients get rid of these symptoms. Not every movement disorder deemed psychological in origin can be treated successfully with hypnosis, guided imagery, and behavioral modification. But these approaches are certainly worth a try.
Dr. London is a psychiatrist with the New York University Langone Medical Center. He has no conflicts of interest to disclose.