Journal of the American Academy of Child and Adolescent Psychiatry

Case Study: Negative Reinforcement and Behavioral Management of Conversion Disorder.

ABSTRACT

Behavioral interventions have been advocated for conversion disorder, but controlled trials are lacking. The authors report the case of a 12-year-old boy with conversion disorder after 3 months of persistent right arm pain and immobility whose symptoms rapidly resolved after an outpatient behavioral intervention using negative reinforcement. The importance of careful assessment, frank discussion of the diagnosis, patient and family psychoeducation, and a rehabilitative mindset are emphasized. Negative reinforcement may be a powerful tool in the management of pediatric conversion disorder, with the potential to reduce parental anxiety and prevent unnecessary physical assessments and interventions. J. Am. Acad. Child Adolesc. Psychiatry 2000, 39(6):787-790. Key Words: conversion disorder, behavior therapy, somatoform disorders, somatization.

Conversion disorder is diagnosed in the presence of one or more symptoms or deficits of voluntary motor or sensory function that suggest a neurological or other general medical condition, but which are not fully explained by the presence of physical disease, the direct effects of a substance, or another mental disorder (American Psychiatric Association, 1994). The symptoms should not appear intentionally or voluntarily produced, and they must cause distress and/or functional impairment and appear to be associated with emotional or psychological factors.

Symptoms suggestive of a neurological disorder in the absence of demonstrable disease are unusual in community samples (Garber et al., 1991; Stefansson et al., 1976), but they are not uncommon in tertiary pediatric referral centers. Nonepileptic seizures, faints, falls, and abnormalities of gait or sensation are most frequently reported (Goodyer and Mitchell, 1989; Grattan-Smith et al., 1988; Lehmkuhl et al., 1989; Leslie, 1988; Spierings et al., 1990; Volkmar et al., 1984). Conversion disorder is more common in girls (Goodyer and Mitchell, 1989) and in adolescents (Stefansson et al., 1976), but it is rare prior to 6 years of age (Grattan-Smith et al., 1988; Lehmkuhl et al., 1989; Leslie, 1988; Volkmar et al., 1984).

Although controlled treatment trials in pediatric conversion disorder are lacking (Campo and Fritsch, 1994), a behavioral approach has been described in case reports. Most have emphasized positive reinforcement for healthy behavior, as well as extinction or withdrawal of reinforcement of the symptom involving minimizing the rewards associated with the sick role (Delameter et al., 1983; Dubowirz and Hersov, 1976; Klonoff and Moore, 1986; Lehmkuhl et al., 1989; Mizes, 1985). Less well described has been the use of negative reinforcement. Negative reinforcement produces an increase in the frequency of a desired response by removing an aversive event immediately after the desired response has been performed (Kazdin, 1994). For example, restrictions theoretically imposed by illness (e.g., being confined to bed) can be lifted contingent upon functional improvement (Delameter et al., 1983; Leslie, 1988; Warzak et al., 1987). We report an illustrative case in which negative reinforcement was successfully used as a c omponent of the outpatient behavioral treatment of a child with conversion disorder. …

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