Treatment of Conversion Disorder in an African American Christian Woman: Cultural and Social Considerations

Initial Presentation and History of Current Illness

Ms. K was a 37-year-old African American woman who was seen in the emergency room in June 1999 with a 1-month history of severe occipital headaches and a 2-day history of dysarthria, difficulty in hearing, and gait difficulties. She was discharged from the emergency room after receiving a computerized tomography (CT) scan of her head, the result of which was negative, and consultation from the neurology service, which found no objective basis for her symptoms. Ms. K returned to the emergency room 2 weeks later, complaining of no improvement in her symptoms and the onset of additional symptoms, including diplopia and vertigo. During a physical examination, a palsy involving the sixth nerve and dysarthric speech were observed, and Ms. K was admitted to the inpatient neurology service.

The noncontrast CT head scan done during the initial emergency room visit showed no evidence of acute intracranial hemorrhage, fractures, or abnormal densities. The results of serum blood tests for HIV and syphilis were negative. The result of a magnetic resonance imaging scan of the brain with gadolinium magnetic resonance angiography also was negative, with no evidence of demyelinating plaques or other disease processes unlikely to be seen on CT. While on the inpatient neurology service unit, Ms. K was found to have a “factitious lateral gaze palsy,” whereby when gazing to the right, she used convergence to adduct her right eye while her left eye moved toward the right. The results of the neurological examination were otherwise unremarkable with the exception of an “astasia-abasia” gait, characterized by underlying “good coordination with the ability to catch herself.” A normal saline placebo was administered, along with the suggestion that the electrolyte solution would ameliorate her symptoms. Slight improvement was subsequently noted in her speech, gait, and eye movements, but the dysarthria did not remit at all.

Shortly after being informed that her symptoms most likely did not have a neurologic basis, Ms. K complained of feeling severely depressed. A house staff officer also stated that she had reported auditory hallucinations commanding her to kill herself. Suicide precautions were taken, Ms. K was placed under one-to-one direct observation, and the psychiatry service was consulted.

Additional History

Ms. K was born and raised in Miami, the third of eight children. Her parents divorced in 1969, when Ms. K was 7 years old. Her father “abducted” her at that time, and she lived with him until age 11, when her mother finally “recovered” her. She reported severe physical and emotional abuse during the 4 years that she lived with her father. She was beaten on average two times a week. She said that she was sometimes locked in a cage for hours at a time with her father’s dogs. According to Ms. K, she was singled out from her siblings by her father because she was the oldest daughter and she most resembled her mother, toward whom her father had substantial feelings of animosity. Despite giving this history, Ms. K insisted that she now loved her father and bore no ill will toward him.

Ms. K reported enjoying school and doing well academically. She participated in extracurricular activities, including the debate team. Her mother was well educated and expected Ms. K and her siblings to achieve. But Ms. K’s ability to continue in her scholastic success was undermined when, at the age of 16, she was raped by an acquaintance. She stated that this traumatic event disrupted her studies, and she was unable to complete high school. Shortly after her withdrawal from high school, she began investing her energy and talents in religious pursuits. Raised a Baptist, she now became a member of the Holiness Church, which was a precursor to the Pentecostal religious movement that emphasizes God’s intervention in human affairs through the Holy Spirit.

At the age of 19, in a match arranged by the church, she married her then 26-year-old husband. They received missionary training through the church and were sent to serve as ministers of a congregation in Atlanta. They had three children, who were 15, 17, and 18 years old when Ms. K was seen in the psychiatry service. She took over the ministry of the church on a full-time basis after her husband was incarcerated on charges of embezzlement. She said that she remained close to her husband in spite of his incarceration and also despite other unwelcome news, including the revelation that he had a long history of homosexual relationships. He died while in prison in 1996 from an AIDS-related illness.

Eventually, Ms. K founded another ministry, an inner-city religious outreach program funded in part by a Lutheran church. For the previous decade, the outreach program had thrived, and through it she operated both a spiritual ministry and a food kitchen. She boasted that she was feeding “300–400 homeless persons per day in [her] spare time.” She lived with her children and had many close friends and associates.

Initially, Ms. K denied any psychiatric history. Nevertheless, she soon admitted that she had experienced depressive symptoms at approximately age 22 but did not seek treatment at that time. She also reported feeling depressed when her husband was arrested and incarcerated for embezzlement. She reported having suicidal ideation at the time but adamantly denied having attempted any self-harm, stating that, “[suicide] is a sin before God.”

Ms. K reported multiple recent stressors and losses. She described having been beaten by men who broke into her house to rob her, saying she thought they had followed her home from the mission. She felt “helpless” at that time. In addition, she was very distressed about the recent rape of one of her daughters. Furthermore, she was also attempting to cope with the news of the out-of-wedlock pregnancy of her other daughter, as well as this daughter’s consideration of the possibility of aborting the fetus. She expressed her guilt about not being close enough to her children when they were younger. She spontaneously interpreted her current symptoms as the result, in part, of a “spiritual attack,” explaining that in her church it is taught that the Devil does such things to people and that faith and prayer are the only remedy.

Mental Status Examination

Ms. K appeared as a sturdily built African American woman, with fair grooming and hygiene, sitting up in the hospital bed. She was friendly and cooperative with the interview, although somewhat guarded. Good eye contact was preserved throughout the interview. She spoke slowly and with apparent difficulty and had an exaggerated Cajun-sounding accent. She made almost tortured-appearing movements of her mouth, with her tongue occasionally clicking loudly against the roof of her mouth. This speech pattern waxed and waned without a discernible pattern, and at times her speech became normal, with appropriate tone and good enunciation. As she spoke, Ms. K gestured in strange, dramatic motions, with her hands flexed backward and fingers stiffly spread in a claw-like posture. Ms. K described her mood as “sad,” and her affect was dysphoric. Her thought processes were slow, but not impoverished, and overall were logical and goal directed. Her thought content was significant for mild grandiosity at times, including occasional mention of personal friendships with well-known persons in Atlanta. When asked about her earlier statements about demons and hurting herself, she explained that the neurology service’s conclusion was a misunderstanding. She clarified that she is a very religious person, and she felt as though she was under “spiritual attack.” She reported having no suicidal ideation during the interview, stating categorically her belief that it is a sin to kill oneself. She reported having no homicidal ideation. Ms. K appeared to have fair insight into the fact that she was under tremendous stress and that this might have contributed to her symptoms. Her judgment and impulse control were deemed good. She scored 26 out of 30 on the Mini-Mental State Examination; she lost points on orientation (2 points), recall (1 point), and repetition (1 point).

Differential Diagnosis

At the outset, the differential diagnosis of Ms. K included neurological conditions, such as multiple sclerosis, optic neuritis, brain tumor, subdural hematoma, early manifestations of AIDS, and neurosyphilis. Multiple sclerosis and optic neuritis could have caused a lateral gaze palsy. A tumor in the area of her vocal cords would result in dysarthria. A subdural hematoma might have accounted for the excruciating headache. AIDS could easily have led to multiple CNS lesions with diverse neurological findings. Neurosyphilis could have contributed to ataxia.

These conditions having been ruled out by Ms. K’s extensive medical and neurological work-up, the differential diagnosis now included psychiatric conditions, such as factitious disorder with predominantly physical signs and symptoms, malingering, somatization disorder, histrionic personality disorder, and posttraumatic stress disorder (PTSD), in addition to conversion disorder. In factitious disorder, in which patients consciously feign symptoms for unconscious reasons, patients often have a coexisting histrionic, borderline, or antisocial personality disorder and typically travel from hospital to hospital in search of care. In malingering, in which patients consciously feign symptoms for consciously understood reasons, it is not uncommon for patients to have pending legal charges or serious financial problems that a new medical diagnosis would conveniently postpone. Patients with somatization disorder typically have multiple symptoms, including pain at multiple sites, gastrointestinal symptoms, and a sexual or reproductive symptom in addition to a neurological symptom. In histrionic personality disorder, prominent symptoms include excessive emotionality and attention seeking, with self-dramatization, theatricality, and exaggerated expressions. In PTSD, a traumatic event must be persistently reexperienced in the form of distressing thoughts, perceptions, dreams, or reliving accompanied by intense psychological or physiological reactivity due to reminders of the event.

Treatment

The attending consultation-liaison psychiatrist evaluating Ms. K (B.J.S.) concluded that the belief in a “spiritual attack” was culturally syntonic and not delusional. Ms. K was given the diagnosis of conversion disorder on the basis of a lack of organic basis for the symptoms coupled with observations of her response to trial interpretations made during the 60-minute bedside psychiatric interview. During this interview, it was learned that Ms. K’s younger sister, an important female family member, had suffered an aneurysm in her leg with resultant paralysis. In addition, Ms. K’s aunt died at the age of 30 from a brain aneurysm, and two grandparents died as the result of strokes. When Ms. K was asked directly if she was angry, she said, “No,” going on to explain that in her faith anger is not acceptable. However, when the psychiatrist said, “Many people in your situation would be furious,” she readily agreed and seemed pleased. Following this clarification, the psychiatrist interpreted, “I think that it is tremendously difficult to be stuck in this situation in which any person would have reason to be angry, even at God, and your faith forbids you to feel angry.” Speaking more fluently, Ms. K reiterated that she was not angry, but she went on to give more details about the terrible events in her life. It was apparent that despite her denial, she was indeed struggling not to feel anger. The psychiatrist then told Ms. K that the inability to speak clearly was connected to both wanting and not wanting to cry out against what had happened. Ms. K became thoughtful, and although she did not agree verbally, her speech continued to improve and her hands relaxed somewhat. She was told that it is important to realize that no human being is perfect and that feeling that she should never be angry becomes a tremendous burden when the people you love let you down. Ms. K then said that as the preacher, she has to practice what she preaches and that she is a role model. The psychiatrist said that sometimes being a role model is very difficult, and Ms. K agreed. These interpretations were carefully tailored not to directly confront Ms. K’s denial.

Given her multiple life stressors and the persisting dysarthric speech and other associated symptoms described earlier, coupled with the improvement in symptoms during the course of the interview, an initial period of inpatient psychiatric hospitalization was recommended. It was hoped that further evaluation and psychotherapy could begin in a safe supportive environment, as the degree of functional impairment was great and might be lasting if not treated intensively from the outset. Ms. K refused. She was discharged from the neurology service and referred for individual supportive psychotherapy with the goal of helping with stress management and addressing some of the underlying issues troubling her. She was seen in weekly individual supportive psychotherapy by a psychiatric resident for approximately 12 weeks. During this period, although Ms. K’s symptoms waxed and waned somewhat in intensity, her condition remained essentially unchanged. Finally, at the urging of her outpatient psychiatrist, she agreed to voluntary hospitalization.

During this hospitalization, gentle efforts were made to explore the relationship between possible social and psychological stressors and the onset of her symptoms. Ms. K seemed to give particular emphasis to events occurring in mid-June 1999, when she was giving a sermon in a church in her hometown of Miami. While talking, she had the sense that she was suddenly hit in the back of the head. She said that she became speechless and then fell to the floor. Her next conscious memory, she recounted, was of being “revived” 2 days later to find herself in a Miami hospital (from which she was discharged with instructions to follow up at the large teaching hospital in Atlanta). While she initially reported that the dysarthria and ataxia followed the headache by at least several days, she now suggested that all symptoms had an acute onset at the time of the sermon. She called this event her “French stroke,” referring perhaps humorously to the peculiar, Cajun-sounding accent with which she spoke in its wake. Ms. K seemed eager to discuss the specific setting in which the “French stroke” occurred and the consequent physical impairments she experienced, but she was quite guarded about possible psychosocial stressors and did not voluntarily identify any specific events that she felt might have been important in symptom formation.

Nevertheless, in talking with Ms. K, several important stressors stood out. First, the episode in mid-June occurred in the context of her first visit in a dozen years to Miami, where she grew up. Second, during this visit she stayed with her mother and began to talk with her mother for the first time in many years about sensitive subjects, including the fact that as a child she had been left to live with her abusive father after her parents’ divorce. Third, Ms. K reported unsuccessfully attempting to visit her father, now a wealthy businessman, and being thrown off the premises of his home by a security guard. She denied knowing whether this attempt to reestablish ties with her father occurred before or after the “stroke” of mid-June, again possibly showing her inability or unwillingness to relate specific stressful events to the conversion symptoms.

On hospital day 5, Ms. K allowed herself to be interviewed and then hypnotized by a psychiatrist with the consultation-liaison service, with the behavioral objective of using suggestion to produce symptom relief. The intention of hypnosis was neither to confront Ms. K with freshly retrieved unconscious material believed to be the cause of her disorder nor to attempt a dramatic cure, but to help Ms. K recall experiences and feelings that she could not consciously bring up in treatment (5). During the interview, she offered more details about the physical experiences associated with her conversion symptoms, but again she was unable or unwilling to provide insight into psychosocial stressors that may have contributed to the formation of her symptom complex. Of note, however, during the hypnosis, her hands relaxed, reverting to almost normal. Her speech became much more fluent and spontaneous. Afterward, her gait was noticeably improved and she walked without a cane. Her dysarthria and awkward hand posturing remained in nearly full remission.

Hypnosis in the hospital proved to be a very productive exercise with Ms. K. She was highly suggestible and was intrigued by her ability to reverse her deficits given the encouragement of the attending psychiatrist. She expressed a desire to learn such techniques, highlighting a conscious desire to be “cured.” While Ms. K was delighted and amazed by her response to hypnosis, she also admitted to feeling anxiety and a “racing heart” during the procedure. She was given a long-acting benzodiazepine, clonazepam, 1 mg b.i.d., to alleviate the anxiety and maintain symptom remission, with the plan gradually to taper the medication when Ms. K became an outpatient. Ms. K took the anxiolytic medication for several days, but she did not like the sedating effects, so it was discontinued.

Ms. K was now receptive to the idea that, given the possibility that her deficits were reversible, there might be some precipitating factors that were blocking her ability to function in her usual fashion. Thus, her inpatient treatment team planned for Ms. K to eventually resume outpatient supportive psychotherapy with her previous psychotherapist in order to address these issues. On hospital day 10, Ms. K was discharged from the inpatient unit to a 3-week partial hospitalization program that was to serve as a bridge between intensive inpatient treatment and her return to everyday life with once-weekly outpatient psychotherapy. At the time of discharge, she continued to believe that she had suffered a stroke. The treatment team did not directly contradict this belief, as such confrontation is generally not helpful for patients with conversion disorder and can generate an adversarial relationship. Although factitious disorder and malingering were considered in the differential diagnosis, the treatment team felt that Ms. K’s symptoms were not under conscious or voluntary control.

Brief Review of Conversion Disorder

Sociocultural Considerations