Twenty-seven patients (60%) met DSM-IV criteria for at least one other psychiatric illness in their lifetime. These disorders included: personality (n = 16; 35%); affective (n = 10; 22%); anxiety (n = 6; 13%); somatization (n = 9; 20%); posttraumatic stress (n = 2; 4%), and anorexia nervosa or bulimia (n = 3; 6%). Seventeen patients (38%) had received psychiatric treatment in the past for one of the aforementioned diagnoses. The identified comorbid conditions were active at the time of our assessments in 11 (24%). It is noteworthy that none of the patients had experienced psychotic symptoms or been diagnosed with schizophrenia, and over 75% had no history of any type of substance abuse.

Prior to the age of 30, BT had no history of neurologic or psychiatric illness. There was no history of substance abuse. She did, however, have childhood asthma, for which she was reportedly hospitalized on multiple occasions before the age of 10.

BT was raised in poverty by an abusive, alcoholic father and a mother who was “always sick” with “leg problems.” She had to assume care for her younger siblings and remembered feeling overwhelmed by their demands. During hospitalizations for asthma she enjoyed a respite from her responsibilities and the strife at home. BT fondly recalled the attention she received from nurses.

Following completion of high school, she married a man from a different ethnic background with a large extended family. There were culturally endorsed expectations that BT would care for her husband’s ill mother and grandmother, as well as help out with the family business. At the same time, she was expected to work full-time, care for their own children, and manage the household. BT attempted to keep up with these multiple demands for a number of years, but felt trapped, deprived, and inadequate. She particularly felt that she was neglecting her own children just as she had been neglected. Shortly before the development of her CD, BT was involved in a minor motor vehicle accident for which she was found to be at fault. While neither she nor anyone else was hurt, a young child was in the other vehicle and BT recalled hearing him cry. In the months that followed, she became “obsessed” with the cry of this child. It was over this period of time that she began to experience the leg weakness, paresthesiae, and bladder symptoms.

In trying to understand BT, why she developed CD when she did, and what issues would have to be addressed and resolved in psychotherapeutic treatment, we considered the factors below.

At the time of our initial assessment, we asked BT to consider that “stress” and “pent-up emotions” might be playing at least some role in her condition. We presented her inability to walk in terms of a simple analogy, comparing her motor system to the engine of a car. If the car will not run, one possible explanation might be a breakdown of some vital engine part. Alternatively, there might be a disconnection between the ignition and an otherwise normal motor. In this case, the car can function if an appropriate starter signal can be restored. BT responded to this notion of a “mind-body disconnection” as an explanatory model for her inability to move her legs. We indicated to her that, in our opinion, her central nervous system “motor” was fundamentally
sound, and that she therefore had the potential for a complete recovery. We emphasized the importance of trying to understand what was causing the “disconnection” at the same time as she received physiotherapy for her motor dysfunction.

BT was hospitalized in our neuropsychiatry inpatient service for 6 months. During this time, all medications were tapered and discontinued. We discouraged self-catheterization and initiated physiotherapy three times a week with a focus upon learning to walk and regaining control over her motor function. Daily psychotherapy sessions were carried out. Much time was spent inquiring about her past life, earlier development, and why she had become who she was. She was also encouraged to talk about her life prior to her illness. Interventions typically involved helping her to correctly identify the feelings that had been aroused in different situations, both in her early life and later in her marriage. We acknowledged her ability to put her own needs aside and her strong sense of responsibility and compassion for others. At the same time, we pointed out the absence of an appropriate sense of entitlement to have her own needs met. Her self-esteem was low and she clearly harbored a deep sense of deprivation. She was also angered by others’ expectations of her. She felt intense, yet unexpressed, anger toward her husband for his role in creating and allowing a situation that recapitulated important aspects of her early life. BT saw herself as a victim and without any control. These unconscious feelings of anger had resulted in significant problems with intimacy as she distanced herself from others, including her husband and her own children, in order to avoid overt expression of her rage. The intensity of her rage—a word she began to use—often frightened her and, although she had no history of aggression, she was concerned that she might hurt someone. Feelings of rage eventually gave way to sadness and she developed a clinical depression, which was treated with antidepressant medication. Efforts to engage her husband in marital therapy were unsuccessful.

Six months after admission, BT was no longer using the wheelchair. She walked with a cane and required assistance in going up and down stairs. At this point she was discharged and seen in twice-weekly psychotherapy by one of us (PR) for the next 2 years. Antidepressant medication was continued during this time. Eight months after discharge, she was walking normally, and within a year she had returned to her factory job. She soon assumed full-time hours and began to coach baseball in her spare time. She initiated a separation from her husband and maintained full custody of her children. At 5-year follow-up, she had remarried, and at 10-year follow-up, continued to work full-time with no relapses of her CD or hospitalizations for other reasons.

In view of the clinical history, we undertook fairly extensive investigations, including a cranial MRI, EMG, muscle biopsy, EEG, evoked potentials, ophthalmologic assessment, cognitive testing, and various enzyme analyses, all of which yielded normal results.

HN came from a stable, well-adjusted family and had a normal upbringing. By temperament she was shy, anxious, and easily frightened. At age 9, six months prior to her first bout of illness, she had witnessed the unprovoked and repeated stabbing of a classmate by another classmate’s mother. She and the child who was assaulted were alone in the school cloakroom at the time. HN did not reveal this history herself and when asked about it replied, “It didn’t really bother me because I was busy tying up my shoes.” Shortly after this horrific event, her dog, which had always
provided her with a sense of protection, died. Despite these events, she denied experiencing any stress other than that caused by her illness.

In arriving at a formulation we considered the following:

While comfortable having a neurologic assessment, HN was initially very upset about seeing a psychiatrist and voiced her concern that our involvement meant she was “crazy” and “imagining everything.” Despite this, she did not resist hospitalization and listened intently to our explanation that she was suffering from a stress-related illness that had caused her to lose control of her legs. We emphasized that investigations had indicated that the “hard-wiring” required for walking was intact, but that her brain was having difficulty “cueing up” the motor program that would normally allow her to walk and use her legs normally. We likened this to a CD player having problems “reading” the information on a particular compact disc, making it impossible to play the recorded music. We explained that stress can be present and affect the body without any real emotional awareness. We put it in terms of stress disturbing the “cueing” function in the brain, with the result that some of the motor “programs” may not get “played” properly. An important, explicitly stated goal of psychotherapy was that she would become more conscious of how life events made her feel so that the “short-circuiting” to her body might be interrupted.