Cite as: Affsprung EH Hysterical Paralysis in an Adolescent Female. Int J Psychopath Psychopharmacol Psychother 1996, 1 (1). URL http://www.psycom.net/ijppp.v1n1.html
A sixteen-year-old female was referred for psychotherapy. The presenting problem was extensive paralysis and considerable pain in both legs resulting in an almost complete loss of her ability to walk. Repeated examinations by a series of physicians had failed to identify any physical cause for her difficulties and it was concluded that the symptoms were psychological in origin. When the patient appeared for her first session, she slowly made her way down the hall and into the office by supporting herself against the wall. In addition to the conversion disorder, the patient was also suffering from a significant degree of depression. The source of the patient's difficulties appeared to be a combination of developmental stressors, intrapsychic conflict, and family dysfunction. Among other things, the patient was contending with a great deal of antagonism between herself and her mother (due, in part, to the mother's own rather serious personality disturbance) and what appeared to be unresolved oedipal tensions between the parents and their daughter. Whatever pre-morbid difficulties the patient had were exacerbated when her attempts at individuation were met with anger and condemnation by her mother and passivity by the father. The daughter's response to her mother's attacks was a retreat into silent, defiant seclusion. A tendency toward repression and an escape into fantasy could be seen prior to the onset of her hysterical paralysis in the patient's recollection of wandering home from school and daydreaming about what her parents and friends would think if she should be accidentally hit by a car. At one point, prior to her therapy, the patient did indeed walk out in front of an on-coming car and was struck. Fortunately, the vehicle was going slowly enough that she escaped serious injury. The actual onset of conversion symptoms seemed to coincide with the patient's transfer to a new and more demanding private school where she felt isolated and inadequate. Treatment consisted of fifteen sessions of once-a-week, individual, psychodynamic psychotherapy over the course of five months. The initial prognosis was not particularly good. There was concern that the patient might soon have to be hospitalized in order to prevent permanent physical deterioration of her leg muscles. In addition, both daughter and parents refused to agree to family sessions and even consultation with the parents proved difficult. Finally, although anti-depressant medication was prescribed by the consulting psychiatrist, the patient refused to participate in the recommended psychopharmacological treatment. Under these conditions and in order to be successful, treatment required a minimum of two things. First, was the provision of a supportive, non-judgemental setting in which this adolescent girl could feel that her thoughts and feelings would be validated. The second involved a facilitation of the patient's recognition and direct and open expression of her previously disavowed grief and anger toward her mother whom she felt did not love or understand her. An important turning point, at about the tenth session, involved the patient's voicing her desire to kill her mother by gouging out her eyes and then cutting off her head. After several months of tears and rage the patient's symptoms began to diminish rapidly (although flaring up temporarily whenever she felt pushed by her parents to recover more quickly). By termination, the patient had completely regained her ability to walk and was reporting an absence of physical pain. Her affect was also noticeable improved. With regard to transference, it was probably fortunate that this patient was not referred to a female clinician. Her antagonism toward her mother (as well as several other female students and teachers in her school and expressed through various reenactments) might very well have prevented her from forming the therapeutic alliance necessary for the rapid gains which were needed to avoid permanent physical damage to her legs. The greatest counter-transference difficulty consisted of avoiding getting caught up in a power struggle with the patient in which she would feel pushed to recover in the same way that she felt pushed by her parents. In fact, during sessions, the patient's somatic difficulties and their eventual disappearance were seldom discussed directly. This case is interesting not only because of the somewhat dramatic quality of the patient's symptoms but also because it would seem to support the idea that one can indeed treat such patients individually, from a psychodynamic orientation, and in a relatively brief period of time. This stands in contradiction to the objections voiced by those (typically structural or strategic family therapists) who argue that adolescent patients with rather serious psychopathology which is related at least in part to family dynamics cannot be treated without working with the family as a whole. It is also interesting to note that although the patient clearly became aware of and was able to voice her heretofore denied feelings of grief and rage, she made her recovery without gaining any significant insight into such things as the actual meaning of her psychosomatic symptoms and acting out (e.g., her suicidal gesture of walking into the path of an on-coming car). Denial such as this may be characteristic of the "hysterical" individual (Shapiro D, 1965) but was probably also due to the patient's youth and a developmentally normal psychological naivete. Certainly, the patient remained vulnerable to future psychological difficulties despite her gains in therapy. Among other things, she would continue to struggle with the problematic family relationships in her home. She longed for the day that she would depart for college although this period of development can, in itself, be quite difficult to negotiate. Nevertheless, the patient left therapy no longer depressed, fully able to walk without pain, functioning well in school, and having made important developmental progress generally.