I wanted to finish off this story with a brief exploration of the other person in this story. Namely the friend. This is really a clinical note to myself rather than an explanation given to my patient. I include it in case it is of interest or value to anyone else. The explanation that seems best suited to this event is conversion hysteria. Defined as
“The diagnostic criteria for functional neurological symptom disorder, as set out in DSM-V, are:
The patient has ≥1 symptoms of altered voluntary motor or sensory function.
Clinical findings provide evidence of incompatibility between the symptom and recognised neurological or medical conditions.
The symptom or deficit is not better explained by another medical or mental disorder.
The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.”
In layman’s terms there is a mismatch between the event and the symptoms. Why should killing the black dog be so problematic for my patient’s friend? One would have expected a feeling of relief .A problem had been solved. There might have been some feelings of loss. A rare and strange creature is no longer present. A challenge has been met and won. But to end up completely paralysed? This makes no sense. During the World Wars it was nor uncommon for some soldiers to be sent home because they had become blind .Or because they had lost the use of their shooting arm. Other expressions of this disorder are:
“In practice, the term is limited to findings on neurological examination that imitate neurological disease, but do not conform to anatomical or physiological patterns. It includes paralysis, somatic and special sensory disturbances, involuntary movements, pseudo seizures, speech, gait, and memory disorders…”
The body acts on behalf of the mind to provide a way out of an impossible solution. If a soldier can no longer tolerate the fighting, what is he to do? He can’t simply go home. He can’t desert. Nor can he stay where he is. One answer is for him to develop a physical condition that allows him a way out. Albeit a physical problem with no organic cause. That way he can leave the fighting and stay alive at the same time.
To return to my patient’s friend. We know from my patient that he and his friend desired the young woman at the end of the lane. For my patient he decided that he had too much to lose by visiting her. His black dog was, ultimately, helpful. It made him evaluate his behaviour in a new way. It seems that his friend reacted differently Which suggests that the black dog had a different meaning for him.
And, as I say to my patients, that is the end of this session. You might want to continue with this material in our next meeting…