CENTER ON BEHAVIORAL MEDICINE
Traditional Approaches-Psychological: Research Article
Behavioral Treatment of Psychogenic Deafness
CITATION: George Mooney, Thomas Gurrister. Rehabilitation Psychology. Behavioral Treatment of Psychogenic Deafness: A Case Report. August 2004, Vol. 49, No. 3, p 268-271.
successful behavioral treatment of conversion disorder presenting as
Adolescent female with psychogenic deafness occurring after an
environmental stressor. Intervention: Participated in 9 outpatient
behavior therapy sessions. Progressed from simple to more complex
hearing tasks after demonstrating mastery at each level.
regained full hearing ability in clinic and in functional settings.
Gains maintained at 1-year follow-up.
Conclusions: Rehabilitation psychologists are frequently involved in the treatment of conversion disorder with motor symptoms, but less often with impairment of 1 of the special senses. This case study illustrates the successful use of behavior therapy in the treatment of conversion disorder presenting as deafness.
successful behavioral treatment of conversion disorder presenting as
deafness. Participant: Adolescent female with psychogenic deafness
occurring after an environmental stressor. Intervention: Participated
in 9 outpatient behavior therapy sessions. Progressed from simple to
more complex hearing tasks after demonstrating mastery at each level.
Results: Individual regained full hearing ability in clinic and in
functional settings. Gains maintained at 1-year follow-up. Conclusions:
Rehabilitation psychologists are frequently involved in the treatment
of conversion disorder with motor symptoms, but less often with
impairment of 1 of the special senses. This case study illustrates the
successful use of behavior therapy in the treatment of conversion
disorder presenting as deafness.
Conversion disorder is defined as a condition in which symptoms or deficits affecting voluntary motor or sensory function suggest a neurological or other general medical condition, but psychological factors are judged to be associated with the symptom or deficit because the onset or worsening of the symptom is preceded by psychological conflicts or other stressors. The condition is primarily not under voluntary, conscious control. Conversion disorder is classified as one of the somatoform disorders in which physical symptoms suggest a medical condition but cannot be accounted for by one.
Conversion disorder presents in a variety of ways. In our experience, motor symptoms or deficits are the conversion disorder presentation most frequently seen within rehabilitation settings. Examples of motor conversion disorder include paralysis, dyscoordination, gait abnormalities, unusual tremors, dysphagia, and aphonia. Sensory presentations such as deafness probably account for far fewer instances of conversion disorder, and for this reason, might be less familiar to clinicians. Sensory presentations may also include loss of touch or pain sensation, deafness, or blindness. Psychogenic involvement of one of the special senses appears to account for approximately 5% of all instances of conversion disorder (Mace & Trimble, 1996; Siegel & Barthel, 1986; Steinhausen, Aster, Pfeiffer, & Goebel, 1989; Volkmar, Poll, & Lewis, 1984).
A number of studies have identified a relation between situational stresses and conflicts and the development of conversion disorder in general (Dvonch, Bunch, & Siegler, 1991; Hryhorczuk, 1981; Rada, Krill, Meyer, & Armstrong, 1973; Rada, Meyer, & Krill, 1969), and psychogenic deafness in particular (Beagley & Knight, 1968; Lumio, Jauhiainen, & Gelhar, 1969; Siegel & Barthel, 1986; Wolf, Birger, Shoshan, & Kronenberg, 1993). These stressors do not have to be unusual or peculiar as long as they are overwhelming enough to a vulnerable individual.
The factors that influence recovery from conversion disorder are not fully understood. Cases of psychogenic deafness with fairly rapid and complete recovery have been reported, usually in the context of a one-time external stressor to which the individual is no longer exposed (Beagley & Knight, 1968; Wolf et al., 1993); in these situations the conversion symptoms rarely recur (Dvonch et al., 1991; Speed, 1996). In some cases recovery is not automatic and treatment is necessary.
A number of studies have identified the successful use of behavior therapy in the treatment of conversion disorder presenting with motor symptoms (Gooch, Wolcott, & Speed, 1997; Parry-Jones, Santer-Westrake, & Crawley, 1970; Speed, 1996; Speed & Mooney, 1997; Trieschmann, Stolov, & Montgomery, 1970), and in one case, with psychogenic blindness (Parry-Jones et al., 1970). One study found successful treatment rates of 90% using behaviorally oriented treatment (Speed, 1996). To our knowledge, this report is the first to describe the use of behavior therapy in the treatment of conversion disorder presenting as deafness.
K.L. came from a benign family background and there was no history of childhood trauma or abuse. She was developmentally normal, had no history of learning impairments, and had been academically successful. She was able to make and keep friends and had participated in extracurricular school activities. There was no history of substance abuse. She had been physically and psychologically healthy. The single exception to this occurred during junior high school when she had vague abdominal pains for which no cause could be found. It was her mother's impression that these abdominal pains occurred in the context of school-related academic pressures.
History of the
K.L.'s problem began at age 16, initially presenting as difficulty hearing and progressing to complete deafness in both ears. The onset of deafness followed shortly after the breakup of a romantic relationship.
K.L. was evaluated audiologically as well as with other specialized testing. She was not believed to have any infectious processes, and a gadolinium-enhanced brain MRI was normal. Audiograms on four separate occasions produced different results on different instances of testing. Conductive hearing loss was present, then absent, then present again on serial testing. There was lack of agreement between the pure tone averages and the speech reception thresholds on all four audiograms. A brain stem auditory evoked response study demonstrated bilaterally normal auditory brain stem pathways. The diagnostic conclusion was of psychogenic deafness.
Following diagnosis, insight-oriented therapy was attempted. During the initial interview K.L. was questioned about a number of topics including history of sexual abuse. She apparently found this line of questioning uncomfortable; it may have taken place prior to the development of a therapeutic relationship when it might have been better tolerated. A mental health referral and the way it was explained to K.L. (implying that psychological factors were thought to play a role in her condition) may have contributed to her resistance toward an insight-oriented approach and her rejection of further mental health treatment.
After this initial trial of mental health therapy, there were no further attempts at treatment for the psychogenic deafness and K.L. continued in her new status as a hearing-impaired student. Her family, her friends, and also her school responded with significant amounts of support and help for the newly developed problem, including a special school program that was organized around her new hearing impairment. Such accommodations and special attention could have provided social reinforcement for the conversion symptoms and made them more difficult to eliminate successfully through treatment.
Approximately 10 months after its initial onset, her condition once again came to clinical attention almost coincidentally when one of K.L.'s relatives was seen in our hospital's neurology clinic and a family history was obtained. During that portion of the family history that focused on K.L., information was obtained that raised the question of psychogenic deafness. A recommendation was made to her parents that K.L.'s original records be reviewed, and following this, the diagnosis of conversion disorder was confirmed. Another attempt at treatment was recommended, which they accepted. Treatment for her was begun again, but because of the previous failure of insight-oriented therapy, it was judged that a behaviorally oriented psychotherapy approach might result in a greater chance of success. Previous studies of conversion disorder presenting with motor symptoms (Gooch et al., 1997; Speed, 1996; Trieschmann et al., 1970) had indicated that acceptance by the client of a psychological diagnosis was not a requirement for successful behavioral treatment of conversion disorder. Additionally, the conversion symptom was believed to be related to a one-time external stressor to which K.L. was no longer exposed. As noted, in such situations favorable recoveries can often occur without much fear of future recurrence or symptom substitution.
The previously described reports of behavior therapy in the successful treatment of conversion disorder functioned as the inspiration for a customized behavior therapy treatment plan for K.L.'s psychogenic deafness. This treatment plan was presented to K.L. in such a way as to de-emphasize the psychological nature of her condition. Instead, K.L. was informed that all of the anatomic structures within the auditory system were intact, but that they would need to be put through a retraining process in order to function normally again. The original precipitating stressor was not brought up for discussion during the course of treatment. The decision to proceed in this way was influenced by K.L.'s previous rejection of a psychological diagnosis.
Nine outpatient treatment sessions were conducted by a speech and language therapist (Thomas Gurrister). Initially, therapy sessions were twice per week for 1 hr, decreasing to once per week toward the end of the treatment.
The overall treatment strategy was to begin at a level within K.L.'s ability and gradually progress toward more challenging hearing tasks by systematically altering some of the relevant dimensions of functional listening. The treatment process was supplemented by significant reassurance and social reinforcement for the progress that was made during treatment. During the first treatment session, K.L. was allowed to supplement the listening process with lip reading. Thereafter, opportunities to visually observe the therapist while speaking were gradually phased out. Initially, the therapist spoke at a normal conversational volume. As therapy progressed, speech volume was decreased. Similarly, distance between the therapist and K.L. was gradually increased over the course of several treatment sessions.
The complexity of the therapy material was also systematically varied. Initially, K.L. was required simply to detect whether a word was spoken. The task difficulty was then increased and she was expected accurately to discriminate target words. When this level of difficulty was reliably mastered, task difficulty increased again and she was required to comprehend sentences. K.L. then progressed to using the telephone, first in the speaker phone mode and then over the hand set. In each case, she did not move on to the next level of difficulty until she had achieved perfect mastery at the preceding level.
By the end of nine sessions K.L. had achieved normal hearing under a variety of functional listening conditions and therapy was discontinued. She actually began making progress very early in treatment, and by the second session, it seemed clear that her ability consciously to hear was unquestionably returning. Indeed, the remainder of the sessions appeared to serve the purpose of redundantly demonstrating the return of hearing and ensuring that the gains had actually generalized to a variety of circumstances. Similar improvements took place in everyday situations including school, at home, and in other social circumstances. K.L. was able to give up the special hearing-impaired accommodations that had been arranged for her at school.
After treatment K.L. was monitored for approximately 1 year. During that time she graduated from high school and began college, where she demonstrated a consistent pattern of academic success with university-level work. She was working part-time and had been successful socially. By the 1-year point there had been no recurrences of the original problem, nor had there been any other symptom substitutions. The durability of successful outcome was confirmed independently by K.L.'s parents.
This case report illustrates a number of concepts of importance with regard to conversion disorder. With an appropriate diagnostic evaluation, conversion disorder can usually be successfully identified. The use of tests that do not depend on the voluntary cooperation of the individual, such as evoked response studies, are perhaps the gold standard tests for this condition and should be included as part of the clinical evaluation. This case report also demonstrates the importance of variability in the clinical findings over the course of serial testing. Clinically unlikely findings (e.g., inconsistency between speech reception thresholds and the pure tone audiogram) also help establish the diagnosis. Finally, the diagnosis of nonorganic deafness is confirmed when the symptoms can be eliminated with brief mental health treatment. Although some of these test results are specific to hearing, the general concepts that these tests represent would be applicable to the evaluation of conversion disorder presenting as other forms of sensory impairment.
How the clinician decides when conversion symptoms should be addressed with insight-oriented therapy or with behavior therapy is an important issue. Closely related to the decision about the type of treatment is the issue of how to inform the individual about the nature of his or her condition. To some extent, these two issues go hand in hand.
A direct discussion with the individual about the psychological nature of his or her condition can sometimes take place rather successfully. No single explanation works optimally for all individuals, but a sensitive explanation of conversion as a rare and severe physical manifestation of psychological stress, in which the communication between the brain and the affected body part is blocked, seems to be well tolerated by most people (Speed, 1996). However, each individual will have a different ability to accept or understand that psychological causes can lead to physical symptoms. It can be harmful for some individuals to be confronted with a psychiatric diagnosis that they are not prepared to accept. The psychologist also needs to keep in mind that for some persons referral to mental health treatment for their conversion disorder amounts to telling them that they have a mental health condition, not a physical one.
Information from several areas can be useful to the rehabilitation psychologist in determining how to inform individuals about their diagnosis and what type of treatment to select. Conversion disorder usually presents first in a medical setting. During interactions with previous medical professionals, they may have been told information about their diagnosis or may have overheard things said about the psychological basis for their condition. Clients can be interviewed about what physicians have told them and then questioned about their reaction to that information. What they have been told and their reaction to it can then guide the psychologist in gauging their readiness to discuss the psychological nature of their condition.
There are other sources of useful information about this issue. Individuals can be questioned about their understanding of the relation between physical health and psychological influences, such as stress. If the individual's health belief model is capable of accommodating a relation between stress and physical health in some area (e.g., stress and cardiovascular disease or stress and tension headache), then this might indicate a greater openness to discussing the psychological basis of the conversion disorder. Finally, psychological measures such as the Minnesota Multiphasic Personality Inventory—2 can also be useful. For example, a clinician might conclude that those individuals with an extremely elevated “conversion V” profile might be too resistant to psychological insight and that a frank discussion of the psychological basis of their condition will be unsuccessful.
This case example exemplifies how communication about the diagnosis of conversion disorder must be handled with unusual sensitivity. Conversion disorders sometimes occur in the first place because of the individual's inability to acknowledge the psychological nature of the condition. This can be true whether the conversion disorder is due to an unconscious conflict or exposure to an overwhelming external stressor. In this case, when K.L. was first referred for mental health treatment there may have been insufficient sensitivity to her resistance to her diagnosis and she refused to participate in any further mental health therapy after the first visit. The effectiveness of behavior therapy does not depend on the individual's insight into the psychological nature of the condition. Even persons with significant levels of resistance can participate in this form of therapy.
The preceding discussion raises a significant ethical issue for the clinician. The client has a right to accurate information about his or her diagnosis. Within a principle-based ethics model, it would be wrong to withhold such information. From a more utilitarian ethics perspective, confrontation of unreceptive individuals with their diagnosis may be harmful and result in their rejection of subsequent therapy that might be highly beneficial for them. Clinicians working with individuals who have conversion disorder are urged to think through these issues, not only from the point of view of treatment outcome, but also with a regard to the ethical problems that they pose.
It is interesting to speculate on the active ingredients of behavior therapy for conversion disorder. It seems likely that people recover from this disorder as the result of several curative factors. Certainly placebo effects and expectancy are part of the recovery process and it is probably appropriate to place some emphasis on the expectation that the individual will experience significant improvement. The use of plausible treatment strategies such as behaviorally based hearing-recovery therapy supports this process. In the case of individuals whose conversion disorder occurred as the result of exposure to an overwhelming one-time stressor that has since passed, the conversion symptom eventually outlives its usefulness, but the individual may not know how to eliminate it gracefully. In these cases, a behaviorally based treatment program may provide a face-saving maneuver to permit the individual to recover. In the present case, therapy was carried out not by a mental health clinician, but by a speech and language therapist. This may have allowed K.L. to benefit from therapy without being distracted by her previous rejection of a psychological explanation of her symptoms. It is implied by certain instances of conversion disorder, where the conversion reaction was a last-resort defense against an overwhelming stressor, that a failure of stress management occurred. In some cases it is probably advisable that the vulnerable individual be trained in improved stress management skills to prevent recurrences, and this can be regarded as another active ingredient of treatment.Rehabilitation psychologists are increasingly involved in the diagnosis and treatment of conversion disorder. Most rehabilitation psychologists' experience with conversion disorder probably concerns motor symptoms or impairment. As behaviorally based treatment of motor conversion disorder becomes more established, rehabilitation psychologists can probably expect to have a growing involvement in the treatment of individuals with conversion disorder presenting with other types of symptoms. This detailed case report illustrates the behavioral treatment of conversion disorder presenting as sensory impairment. Although our focus is on the treatment of nonorganic deafness, the techniques described here could readily be modified and applied to the treatment of other sensory presentations of conversion disorder.
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