Download Counter Threat Therapy (CTT) Threat Substitution Therapy (TST)

Counter Threat Therapy (CTT)
Threat Substitution Therapy (TST)
In the treatment of conversion
disorder-A Case Report
By Dr. Machanga Mareko
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).
CTT/TST: Background
• The brain processes threatening information largely
automatically/unconsciously, using its rule bookdeveloped 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”?.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
CTT/TST for conversion disorderdiscussion
• 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.
CTT/TST for conversion disorderdiscussion
• 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.
CTT/TST for conversion disorderetiology 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.
CTT/TST for conversion disorderetiology 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.
CTT/TST for conversion disorderdiscussion
• 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).
CTT/TST for conversion disorderdiscussion
• 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.
CTT/TST for conversion disorderdiscussion
• The characteristics of the CTT were: nonmalfeasance-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.
CTT/TST for conversion disorderdiscussion
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.
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 reevaluate the initial threat with the aim of
extinguishing it and therefore removing the
“freeze” response.
Thank you