The so-called dissociative phenomena are explained by Kihlstrom as follows. The information is not processed explicitly; the patient does not consciously perceive an object or remember a happening. Implicitly, however, the stimuli do influence the patient's behaviour. These observations support the view that there are two memory systems: the explicit memory system and the implicit memory system (Schacter, 1987) or memory with and without awareness (Jacoby & Dallas, 1981). A similar distinction is suggested for perception (Kihlstrom 1992b). Alongside implicit memory and perception, Kihlstrom (1992b) talks of unconscious emotion and cognition as information processes that can influence ongoing experience, thought and action, outside of the phenomenal awareness.
Dissociation and the hypnotic trance are closely related. Hypnosis can be seen as an altered state of consciousness in which it is possible to focus the attention in a particular direction and thus easily achieve a state of muscle relaxation. During this procedure it is possible to change a subject's experience of pain, cold, heat and other sensory perceptions (Frankel, 1978). This kind of altered perception could also occur in patients with conversion symptoms. Patients feel their legs are paralysed and behave like someone whose paralysis has a physical cause. They see that they are paralysed and feel paralysed. Under hypnosis, disorders such those seen in conversion patients can be evoked and made to disappear again in very suggestible subjects.
Research carried out by Bliss (1984) revealed that patients who suffer from a conversion disorder are exceptionally suggestible. The Stanford Hypnotic Susceptibility Scale (Form C, range 0-12) was used to measure the suggestibility of 18 patients. Their average score was 9.7 ± 0.48, significantly higher than that of a control group of cigarette smokers (6.6 ± 0.37). The conversion patients' average places them in the top 10% of the population with regard to suggestibility. This is the level of suggestibility required for a subject under hypnosis to have auditory hallucinations or negative visual hallucinations (not seeing things which are actually there). Bliss (1984) suggests that the ability to put oneself very rapidly into a state of trance (the hypnoid state) can be regarded as a primitive defense mechanism. The conversion symptoms might therefore be brought on by self-hypnosis.
A reflection of this can be found in the animal kingdom. When danger threatens animals might flee or, if they are suitably equipped, fight. There are times, however, when the enemy is too powerful, too strong or too fast. For these situations some animals have a third possibility, the 'Totstellreflex', or 'playing possum' as it is more commonly known in English. A good example of this is the mouse that appears to be dead when carried into the house by the cat, but who later runs away. The reaction can also be seen in insects such as the dung beetle, in spiders and in fish. Anglers are very familiar with the sight of a large bream floating on its side for a while without moving after having been caught and thrown back in the water. Similar behaviour can be found in birds, crocodiles, snakes, chickens and guinea pigs.
A reaction similar to the 'Totstellreflex' is the way some animals suddenly feign disability. Taylor (1986) describes, for example, how a curlew with young chicks imitates the behaviour of a bird with a broken wing to distract a bird of prey away from the nest. Similar violent, almost uncoordinated motor reactions are also seen in various other animals exposed to extreme threat. When captured, a bee will buzz around as though demented; a bird caught in a room will flutter desperately, flying against walls and windows in its panic.
In animals these phenomena are survival mechanisms triggered by danger (cf. Hoogduin, 1988). In people, too, the dissociative reaction seems to be a way of coping with extreme circumstances.
The following points can be made in summary of the foregoing:
• Patients with conversion symptoms develop the disorder when they have been, either long term or momentarily, in severely threatening situations.
• There are indications that a similar mechanism lies at the root of both conversion disorder and dissociation
• Conversion symptoms resemble states or conditions that can be induced through hypnosis.
• Conversion symptoms resemble behaviours sometimes observed in animals at moments of extreme threat.
THE HYPNOTHERAPEUTIC STRATEGY (Hoogduin & van Dyck, 1990,1992)
Van Dyck and Hoogduin (1989) divided hypnotic intervention into two broad categories: symptom directed and exploratory. The former is the older of the two and consists of the creation of a state of heightened suggestibility in order to influence symptoms in a favourable way. In the exploratory approach, techniques such as revivification or age regression are used in order to discover the possible cause of the symptoms. This may be followed by symptom-directed suggestions.
The procedures described here are a combination—where possible—of both these strategies. Firstly, investigations were carried out to discover whether the onset of the conversion symptoms had been preceded by some traumatic experience. If so, revivification was used, followed by an attempt to influence the symptoms both directly and indirectly. Where no psychological trauma was discovered, the approach was limited to direct and indirect influence of the symptoms.
The treatment strategy suggested here is therefore the following:
• A rationale, explaining that the symptoms are the result of strong emotions which the patient has been unable to deal with and that, by reliving the event which gave rise to the emotions, these will be re-experienced and dealt with, causing a reduction of the symptoms.
• Formal trance-induction with revivification during which the patient is encouraged to give free rein to any emotions.
• Post-hypnotic suggestions: at the end of the session, the post-hypnotic suggestion is made that the patient will be able to continue dealing with the emotions, e.g., at night during sleep in the form of dreams.
• The use of direct and indirect suggestions to reduce the symptoms.
• Training in autohypnosis using audio-cassettes.
• Face saving: this can be ensured by emphasizing the importance and gravity of revivification, preferably in the presence of the partner or parents of the patient. Giving the treatment an aura of importance and gravity ties in with the rationale of the patient's being unable to deal with such intense emotions earlier.
• Rehabilitation: when improvement occurs in symptoms which have existed for years, good physiotherapeutic rehabilitation and guidance are essential.
• Influencing stress factors which have contributed to the onset of the disorder.
• Influencing any possible reinforcement of the disorder by those close to the patient. This often involves correcting the attitude of the partner or parents who often play a significant role in sustaining the notion that the disorder is physical (Taylor, 1986).
• When no indication is found that revivification is necessary, this element is left out of the procedure. The rest of the treatment strategy remains the same, i.e., direct and indirect influence of the symptoms, a plausible rationale, formal trance-induction and post-hypnotic suggestions. Face saving, rehabilitation and influencing any possible antecedent or consequential factors also remain part of the treatment strategy.
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