1. Counter Threat Therapy (CTT) Threat Substitution Therapy (TST) In the treatment of conversion disorder-A Case Report By Dr. Machanga Mareko

2. CTT/TST: Background CTT is a novel concept. No descriptions exist on CTT. Basis of CTT is that, all animals do, man inclusive, is deal with threats-what most authors prefer to call stress, every day of their lives. All threats endanger the lives of animals. Animals deal with threats using their brains-via effectors like muscles, mouth, venom etc via survival behaviors like fight, flight, fright or freeze (the four fs described by WB Cannon).

3. CTT/TST: Background The brain processes threatening information largely automatically/unconsciously, using its rule book- developed over millions of years. For example, when you see a snake, you jump or run before finding out whether it is poisonous or not or indeed a plastic one! This is critical given that brain information processing is prone to errors!-a computer will give the same output for a given input but for the brain the output is never the same; and our penchant for indecision-does “spoilt for choices ring a bell”?.

4. CTT/TST: Background Conversion disorder is always preceded by a threatening/stressful event, even if by as many as fifteen years. The threat is of such a magnitude as to endanger the survival of the sufferer. According to S. Freud, the repressed feelings (anxiety) of a threatening/stressful event, mostly of a sexual nature, are “converted” into physical symptoms. Although conversion disorder has been known for a millennia, its etiology and treatment remains highly debated.

5. CTT/TST: Background There is no consensus on the etiology of conversion disorder. Conversion mechanisms, suggestibility, evolutionary postulations and brain laterality have been postulated as possible etiological constructs but there has been no consensus among researchers. Neuro-imaging studies have implicated blood flow problems in the brain but the numbers have been few for generalisability.

6. CTT for conversion disorder-case report A 39 year old female patient presented to the Mental Health Department on 27/10/2010, as a referral from the ENT Department with a diagnoses of psychogenic dysphonia, after all their investigations turned out as normal. She told the counselor that her problem started on 3/6/2010 when her boy friend broke up their seven-year old relationship, that was to culminate in marriage, after she informed him that she was suffering from primary infertility.

7. CTT for conversion disorder-case report He told her that he would not marry a barren woman because he needed children. She reported that she started experiencing headaches, lack of sleep, depression and lost her voice. Two paternal uncles suffer from diabetes and hypertension; a maternal uncle is alcoholic. There was no family history of mental illness, epilepsy and she had no previous history of any medical or mental condition.

8. CTT for conversion disorder-case report She is educated up to form 4, a secretary at a primary school (14 years) and was raised by both parents. She was noted to be crying a lot and expressed feeling helplessness, with fleeting suicidal thoughts without plans. A diagnoses of conversion dysphonia was made and she was taken through counseling which consisted of loss meaning, disclosure, irrational thoughts challenge and relaxation skills training.

9. CTT for conversion disorder-case report Was advised to write an unsent letter to her boyfriend and was given an appointment on 3/11/2010. She came on 3/11/2010 and was still tearful when she talked about the broken relationship. She reported a poor appetite and sleep. She was feeling guilty, helpless and withdrawn. She was still dysphonic.

10. CTT for conversion disorder-case report During this session, guilt feelings were explored and ventilation was facilitated, the homework was reviewed, benefits of disclosure were discussed, cognitive triad (thoughts feelings and behavior) were discussed. She was given an appointment for 16/11/2010.

11. CTT for conversion disorder-case report On 16/11//2010, she was noted to be cheerful but was still having poor sleep and appetite; and dysphonia. She was still withdrawn and had not disclosed to anyone. Benefits of disclosure were discussed and was encouraged to move on with her life dysphonia notwithstanding. Her gyne predicament was discussed and adoption was encouraged.

12. CTT for conversion disorder-case report She kept the appointment of 30/11/2010 during which time she was cheerful and well groomed and had disclosed to her mother and sister which made her get some psychological relieve. She was still dysphonic, her appetite was still poor but she was sleeping well. Automatic thoughts were explored in relation to how they were affecting her feelings and behavior and she was advised to counter them with positive thoughts.

13. CTT for conversion disorder-case report She was challenged on when she wanted her voice back and instructed to apply self talk until she regained her voice. She was advised to seek a second gynecological opinion. She kept the 1/2/11 appointment in which she was reviewed by the psychiatrist. It is not clear whether there was a consultation to this effect. She told the psychiatrist that she was having poor appetite and sleep, low energy, headaches and had not reported to work for the previous one week. She looked kempt, fully oriented, had low mood, was tearful and was whispering.

14. CTT for conversion disorder-case report Supportive counseling was done and she was put on amitriptyline 25 mg nocte. On 1/3/2011, she presented to the author complaining of head ache. (again not clear whether through a consultation). She was well groomed though talking in whispers. Voice loss mechanism was explained: The ENT team found nothing wrong in her phonation apparatus (hardware) therefore the problem must be at the level of “willing to speak” (software) in the brain-not the mind.

15. CTT for conversion disorder-case report The author informed her that it was not unusual for people to lose their voices along with their valued goods eg speechless moments. In her case she lost her voice along with her boyfriend. The author suggested she seeks divine intervention by asking her Father (she is a catholic) to intercede on her behalf. Amitriptyline was stopped and she was given a one week’s appointment.

16. CTT for conversion disorder-case report She presented again on 8/3/2011, this time without a headache but still dysphonic. The author pointed to her that since divine intervention had failed, there was only one option left: Electro-convulsive therapy (ECT). The author informed her that ECT would entail admission for about two weeks in which she would undergo at least six sessions of ECT under general anesthesia, and this treatment would cost her at least a hundred and fifty thousand shillings.

17. CTT for conversion disorder-case report The author informed her that ECT’s most serious side effects included transient memory loss and rare anesthetic related deaths. Finally, the author informed her that the efficacy of ECT in the treatment of her condition was not well established. She was advised to consider this option and return after one month for a way forward.

18. CTT for conversion disorder-case report She came on 5/4/11, cheerful, and informed the author that she woke up one morning (date unknown) and found that she could speak.

19. CTT/TST for conversion disorder- discussion The author postulated that since threats precede all conversion disorders, then the automatically/unaware/involuntarily processed threat management system of the brain must have a defect. Therefore, the question was whether covertly countering/substituting this automatically processed threat with a voluntarily processed threat would be beneficial.

20. CTT/TST for conversion disorder- discussion The next step was to identify the threat(s) 1.Starvation (selfish). Boy friend money food social status 2.Emotional deprivation. 3.Although city dwellers are rarely faced with our primeval threats-predators, we still retain the capacity to react via the four fs, when faced with starvation when money is made scarce by donor support withdrawal.

21. CTT/TST for conversion disorder- etiology discussion Physiologists have long known that, when faced with a threat, animals respond by fright, flight, fight or freeze (the four fs). Since conversion disorders almost always present with loss of function, the author postulated that the deficits seen in conversion disorder may be the evolutionary footprints of the four fs, particularly the freeze response.

22. CTT/TST for conversion disorder- etiology discussion The four fs are processed automatically/unconsciously via the brain’s threat processing system honed over millions of evolutionary years. Symptoms in conversion disorder occur automatically and suddenly.

23. CTT/TST for conversion disorder- discussion The dysfunction in threat management-what I call brain processing errors-generate involuntary decisions that manifest as the conversive behaviors that ensure the survival of the person. In this case the patient partially lost her voice (she was speaking in whispers-people speak in whispers when faced with a common threat).

24. CTT/TST for conversion disorder- discussion This ensured that the defect did not further compromise her survival as she had to communicate her predicament to her boyfriend (hoping that he would reconsider-seeing her so suffering) and later to the medical team. The purpose of the spiritual intervention was to exhaust all other avenues of help to prepare her for CTT. After spiritual intervention failed, CTT was instituted.

25. CTT/TST for conversion disorder- discussion The characteristics of the CTT were: non- malfeasance-there are anecdotal reports of ECT’s efficacy, same threat but of a higher magnitude than the one causing the conversion disorder-its unlikely that this boyfriend had given her more than a couple of thousands as compared hundreds of thousands she would have to pay as medical bills, “diciness”-planting seeds of doubt in her brain-the aim is not to do ECT but to engage her brain in threat re-evaluation.

26. CTT/TST for conversion disorder- discussion Did CTT work? The jury is out there. The fact though is that she improved in less than one month following CTT, while her voice had remained unchanged from October 2010 to February 2011 despite intense psychotherapy.

27. CTT/TST for conversion disorder-model Initial threat covertly countered by a threat of a similar nature of a higher magnitude whose implementation, though not the goal, is beneficial. The brain decision making processors are activated in order to re- evaluate the initial threat with the aim of extinguishing it and therefore removing the “freeze” response.

28. Thank you