| Accept the problem | Clinicians start by stating that they accept the reality of the patients' problem and want to work with them to improve it |
| Agree to a shared understanding | A shared understanding of the problem is an essential foundation for treatment. Explore the degree of confidence and understanding that patients have in their diagnosis. Improve that confidence by addressing doubts and reiterating the positive basis for the diagnosis and a rehabilitative approach to treatment. Ideally, therapists should be able to show the physical signs (eg, Hoover's sign or distractible tremor) to patients in order to improve their confidence. |
| Agree treatment goals | Ascertain what patients want and agree on specific practical goals (eg, walking to stores) |
| Identify unhelpful cognitions | Explore the patient's thoughts and beliefs about their symptoms. As an example, patients with a left hemiparesis may believe that they have had a stroke. Other common thoughts are that the disability is fixed or that doing more will make symptoms worse (or cause bodily "damage"). Diaries of thoughts and behaviors in specific situations may be helpful. |
| Identify unhelpful behaviors | The most common are forms of avoidance. As an example, patients with leg paralysis may be reluctant to move because walking is tiring, painful, or socially embarrassing. Patients with nonepileptic seizures may fear the consequences of an attack and thus avoid crowded situations. |
| Challenge unhelpful behaviors | It is often helpful to work on behavior first. Behavioral change requires the gradual reduction of avoidance behavior and other maladaptive behavioral responses to symptoms. Goals must be specific, attainable, and valuable to the patient. It may be helpful to work with a physical therapist. |
| Challenge unhelpful cognitions | Evidence for and against beliefs can be reviewed. As an example, the experience of behavior change can be used to challenge cognitions about the impairment being fixed. |
| Involve the family | Key family members may be invited to attend treatment sessions so that they understand the rationale for the diagnosis and treatment plan. In addition, they need practical advice about how they should respond to symptoms. As an example, a nonepileptic seizure should be handled like a panic attack in a calm and reassuring way, not with drugs and a phone call for an ambulance. |
| Encourage practice | Improvement is usually gradual. The desired behavior is practiced daily until it is mastered, and then the next goal is undertaken. As an example, patients with functional paralysis who ultimately want to walk to stores may have to start by walking round their home, until they feel progressively less tired as a consequence. |
| Anticipate fluctuations | It is unusual for patients with conversion disorder to improve continuously without any setbacks. Symptoms typically improve then relapse, or attacks resolve and then recur in a cluster. |
| Consider teaching relaxation and distraction techniques | Relaxation techniques (eg, progressive muscle relaxation or breathing retraining) can aid coping with unpleasant symptoms. Distraction techniques such as those used in panic disorder (eg, speaking to someone or mental arithmetic) may help generate a sense of control over attacks or exacerbations of symptoms. |
| Encourage patients to consider a psychological etiology, but do not insist upon this | Although many patients can eventually realize the relationship between their symptoms and psychological problems, it is not always necessary for a successful outcome. As an example, patients may come to appreciate that their dissociative experiences and lack of bodily control arises from childhood abuse. Ensuring that such links are actually present and are elicited in a way that is helpful rather than harmful to the patient requires time and experience. Patients should dictate the speed with which these links are made, not the therapist. |
| Use problem solving to address practical problems | Problem solving can be used to help patients address obstacles to recovery, such as difficulties with relationships, work, finances, and legal issues |
