Treatment protocol of Hysteria (Conversion Disorder, Dissociative Disorder, and other variants)

A. General treatment:

1. Explanation, support and advice to the patient and caregivers
Explain the nature of disease, cause, psychopathology, treatment and outcome in their understandable way. Don’t oversimplify, like nothing needs to be worried or nothing is wrong with the patient that may create neglect of the patient or caregivers might believe that patient is feigning and can be expressed by humiliating the patient. Alternatively, don’t be overly concerned that it can increase reinforcement and attention seeking of both patient and caregivers.

2. Hospitalization
If patient warrants crisis intervention, is stupors, needs further steps for exclusion or evaluation of organic aetiology, marked behavioural problems including excitement, when stressor or conflict is unexplored in routine procedures, for minimising overprotection and secondary gain, and when the family are not in a position to receive treatment in OPD basis. However, keep in mind hospitalization for long duration can slow remission and exerts abnormal illness behaviour and chances of relapse immediately after discharge.

3. Symptomatic treatment
Maintenance of adequate food, nutrition and vitals
If insomnia – give sleep hygiene and hypnotics for short duration if necessary
If anxiety and distress – relaxation and anxiolytics
If hyperventilation-relaxation, breathing in polythene bag

4. Maintenance of active daily living program
Initially minimum with gradual increase of activities. Set it with discussing patients on “as much as you can” basis.

5. Reduce secondary gain or reinforcement-
Show empathy with firmness. Manage over concerns and worries of caregivers, and their overprotective behaviour if any, don’t use unnecessary interventions or placebos. Avoid unnecessary investigations. If necessary, explain it. For example, “I’m giving some routine examination just to check your general health status as we give routinely” or I’m giving this investigation due to your this physical health matters, not related to your present problems. Be careful from any neglectful act that can’t be equated with the means of reducing gain.

B. Specific Management

1. Minimising symptoms of hysteria
Suggestion- This component of treatment should start initially and can be tested by the patient’s level of suggestibility earlier during clinical examination. Provide simple suggestions for minimizing symptoms and encourage them to do so in front of you. Encourage the patient if he/she does the task. It may be a relaxation, graded task towards normality as deems fit. If necessary, give hypnotic suggestions. Give practising tasks and ask them to show you a letter. Engage nurses or co-workers to monitor the task and support patients. It is expected that the patient will engage in the task. You just need to keep his/her motivation for gradually increasing the task towards normality.

2. Resolution of stress or conflict
It is the core of the whole treatment. Ensure that you’ve identified the stressors or conflict correctly. If you’re unsure, do exploratory psychotherapy, and if necessary, do aided psychotherapy like an amobarbital interview or abreaction. Remember that a patient might have one or more stressors or conflicts or psychosocial distress. In that case, usually one plays as primary and others are antecedents or consequences. If you are sure, discuss freely the matter with the patient, and also with caregivers to select one of the following options:
a. Removal- removing the cause that creates stress or conflict. This is ideal but most of the cases not possible or feasible.
b. Modification- modifying the cause of stressor or conflict at acceptable level.
c. Acceptance- accepting the cause of stressor or conflict without any change that is either removal or modification is not possible or plausible in any ways.
If necessary, apply problem solving strategies, counselling, supportive psychotherapy, cognitive therapy, and insight oriented psychotherapy, family counselling to make them clear about proses and cones of all the options so that patients can adopt any of the above options. Always keep in mind that you should act as facilitator not a decision maker though you need to show your concern and active role as a physician.
After selecting an option, work for the strategy and actions that require immediately and afterwards. Define the role of everyone for achieving sustainable outcomes. Carefully observe the patient’s thoughts and behaviour that can go as either relax or further distress. If it proves a wrong decision of selecting options, work on it again with enthusiasm.

C. Preventive Measures
This will be aimed from initiation of treatment and should be the main focus during follow-up.

1. Working with patient
a. Any vulnerable component of a patient’s personality traits like anxiety prone mood, poor stress coping ability, dependent, avoidant, uncontrolled emotion, misperception of social cues, tendency to see and deal with the environment only through their own perspectives.
For this stress coping, assertion training, social skill training, CBT can be used
b. remedial education and other measures of rehabilitations with the aim of regaining premorbid functional status.
c. establishing or rebuilding if necessary a patient’s social network.

2. Working with family
b. managing dysfunctional family, unhealthy parental behaviour, family conflicts including marital discords by positive parenting, family therapy and couple therapy where appropriate.
c. Developing supporting measures in the family partly sharing and communication

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