Long-term prognosis of psychogenic visual disturbances (PVD) in children
following SAT therapy

Noriko Higuchi and Tsunetsugu Munakata
Department of Human Care Science, Graduate School of Comprehensive Human
Sciences, University of Tsukuba
Correspondence: n.higuchi@jcom.home.ne.jp, munakata@hcs.tsukuba.ac.jp

Abstract
OBJECTIVE:

This paper aims to (i) evaluate long-term prognosis of PVD after

Structured Association Technique therapy based on recurrence rate and changes inbehavioral characteristics, and(ii) elucidate the factors that play a role in therecurrence of PVD.
METHOD:

The targets of this study were 17 cases diagnosed with PVD. Tenchildren who recovered under SAT therapy (SAT) and 7 children who recovered underconventional therapy (C.T.) Their parents agreed to participate in the study andcompleted the self–administered questionnaire. The follow up survey for the medium-term
prognosis study was conducted in July 2002, while the long-term prognosis study was
implemented in July 2004.
RESULTS:The following findings were obtained. 1）Recurrent numbers for eachmethod of therapy was 2 out of 7 patients (28.6％ ) in the conventional-type therapy
group at the medium-term prognosis observation time point, whereas it was one case outof the 10 subjects (10.0%) in the SAT therapy group.
significant difference noted.

There was no statisticallyAt the long-term prognosis observation time point, visualInternational Journal of Structured Association Technique No.3

1

disturbance recurrence was seen in 1 out of 5 patients in the conventional-type therapy
group, whereas recurrence was not seen in the SAT therapy group.

Therefore, in bothgroups a significant difference in visual disturbance recurrence was not seen even at thelong-term prognosis observation time point.

In the SAT therapy intervention group,scores of self-repression, emotional dependency, and trait anxiety that improved soonafter intervention remained low even though there was a slight increase at the long-term
prognosis observation time-point. Similarly, scores of self value and degree of awarenessof mother’s emotional support similarly remained high, though there was a slight drop.
On the other hand, scores of self-repression, self-esteem, trait anxiety, and perceived
emotional support hardly changed in the conventional-therapy group. In the PVD
recurrent cases, it was confirmed that anxiety,self-repression, and emotional

dependency were high though an improvement was temporarily seen, and self-value anddegree of awareness of mother’s emotional support were low, thus accompanying achange in psychological characteristics.
These results suggest that since psychological conflicts were behind the outset of
PVD, therapy should not focus on resolving superficial issues such as visual disturbance,but should involve psychological interventions to find solutions to observed psychologicalconflicts.

International Journal of Structured Association Technique No.3

2

1. Introduction
1.1

Aim
Psychogenic visual disturbances (PVDs) cause abnormal visual performance. For

many years its cause was unknown, as was the explanation for the resulting poor vision.
The incidence in pediatric ophthalmology patients is reported to be approximately 1%(Yokoyama, 1999) 1) .

Recent development of imaging diagnostic technology has enabled

the identification of reduced blood flow to the visual association area as a cause of PVD(Okuyama, Kawakatsu, Wada & Komatani, 2002) 2)
Somatization disorders such as those seen in children with PVD, arise as a result ofstress revealing itself as a functional disorder of the body or a transformation of the
conscious mind, without the patient being aware of it.

Such disorders are often seen inchildren whose body and mind have not properly differentiated 3) .

These children aresaid to have the tendency to relieve stress by converting it to a physical symptom rather
than finding a solution psychologically, perceiving stress as stress 4) .
The present authors have so far reported that children with PVD have stressful
psychological characteristics such as a low self-esteem, high anxiety, and show
self-repressive and emotional dependency characteristics 5) .

It is widely known that such

psychological characteristics accumulate stress, easily cause worry and anxiety, andtrigger psychobiological reactions (interactive reactions involving the autonomous
nervous system, endocrine system and the immune system) 6) due to suppression offeelings and desires without expressing them.

Therefore it was thought that thephysiological characteristic of building up stress influences the onset of PVD throughsuch mechanisms.
Research reports relating to long-term prognosis of PVD are scarce, with only a few
that center on eyesight observations 7-9) and extremely few case reports 10) .

International Journal of Structured Association Technique No.3

There are3

hardly any reports on detailed long-term observation through active psychologicalintervention.

The various therapeutic approaches to PVD are mostly psychologicaleducation and advice 11)-12) .

Conventionally, psychotherapies for PVD used approaches

that tried to reach memories and experiences of psychological trauma in early childhood.
However, many evidences which memories of latent psychological trauma experienced in
the fetal stage are recently being revealed. Then,in the present study, a prognosis
evaluation will be conducted using a new psychological intervention that tries to approach
memories of latent psychological trauma experienced in the fetal stage.

This paper

aims to (i) evaluate long-term prognosis of PVD following Structured Association
Technique therapy (SAT) 13) based on recurrence rate and changes in behavioral
characteristics, and (ii) elucidate the factors that play a role in the recurrence of PVD.

2. Method
2.1 Subjects
The targets of this study were 23 cases diagnosed with PVD at A University Hospitalfrom April 1999 to March 2003; subjects with organic symptoms were excluded.

The

chosen subjects did not show improvement of eyesight during the observation period of atleast two months or more prior to intervention and included cases with psychogenic
abnormal visual fields and abnormal color vision. The subjects who finished theirtreatments

at least one year

before were recruited for this study. Informed consent

was obtained from patients and parents prior to participation in the study.

2.2

The method of intervention and treatment termination criterion

2.2.1 Intervention by SAT therapy
Conventional psychotherapy focuses on unresolved issues from early childhood andInternational Journal of Structured Association Technique No.3

4

tries to raise awareness of the issues that reconstitute the mental attitude 14) .

Recently

Van den Bergh et al. 15), in their fetal programming hypothesis, reported that the degree ofanxiety of the mother in the early gestation period is likely to hinder brain development of
the baby and that this degree of anxiety correlates with childhood ADHD and height ofanxiety 16) .

They described that when the mother’s degree of anxiety is high during thisperiod, the mother’s cortisol has an effect on the baby through the placenta and may
affect development of the HPA system, limbic system, and prefrontal cortex 17) .

In SAT

theory, it thought that the presence of such pre-birth trauma makes it easy to draw out
image memories accompanying aversion system affects, and that these mutual influences
cause misinterpretations in reality perception.

Thus SAT tries to work on memories offetal life and infancy using emotions and body sensations as clues.

Image memories ofthe fetal period that are unperceivable during normal consciousness are aroused using
hypnosis-mediated fetal stage image induction from fetal sensations while expressing theemotions.
The main technique used in SAT therapy is to modify the self-image script.
Hypothesizing first that through flashback on past problems the client is currently awareof, SAT tries to identify those negative experiences of the past.

Then, in order to findpositive meaning within the associated negative images, image script formation is done
through re-learning, re-talking, re-imaging, re-acting and physical contact.

As a resultof these, SAT aims to secure a new self-image. These are several reports that a brain
activation

which is related to imagery

similar to actual experiences

was evident .

Therefore, a similar consequence is obtained when imaging and when actuallyexperiencing the same experience 18) .

Thus SAT therapy considers the formation of adetailed and vivid image to be highly important.
In order to achieve this, SAT therapy centers on approaching latent,

International Journal of Structured Association Technique No.3

5

unconscious traumatic memories in the child, changing the images associated with thenegative feelings, and forming a reassuring image.

Specifically, SAT (i) grasps strong

traumatic feelings (terror of being abandoned, self-denial, sadness and sorrow) that thechild is currently aware of, elucidates the voice within that expresses those feelings,
clarifies the key circumstances that are common to these situations, and promotes thechild to image such that the emotions of traumatic scenes of the past are temporarily
awakened; (ii) during the emotion awakening, the child is made to recall images of the
fetal period and infancy, including physical sensations; (iii) from the drawn out sensations,the child is helped to realize latent emotions and wants, and a desired scenario such as“what he/she really wanted” is created. Based on this scenario, a role-play is performed
to change the images to parental images that the child considers to be soothing, andimages of parents welcoming the pregnancy and delivery. At this time the therapist
creates an image that satisfies the desire and craving for affection and employs thesomatic communication method (physical contact method) with the child.
The method implemented in this study sets specific action goals for finding
solutions to actual problems the child faces at the moment, conducts a rehearsal taking
practical use of social skills, and assists the mental and physical growth of the childhimself by actively supporting the solution of the real issues behind.

This is done byenhancing the feelings of efficacy attained through solving problems by oneself.
duration of intervention per session was 30-40 minutes.

The

At commencement, art therapy

was done, making efforts to enhance the expression of inner feelings and rapport building.
SAT therapy was then performed in 2-3 sessions.

These interventions were performedby the authors who are qualified Orthoptists with adequate knowledge and experience intesting and treating patients in the fields of Ophthalmology and Orthoptic Correction, and
who are also qualified image therapists approved by the Heath Counseling Society.

International Journal of Structured Association Technique No.3

6

2.2.2

Conventional-type therapy
This is a treatment practiced by University A which mainly involves hypnotic

eyeglass prescription, placebo eye-drop prescription, advice giving to parents to improvethe environment, and so on, conducted by the 0phthalmologist in charge of the patient.
This is a general method widely used in Clinical Ophthalmology.

Environment

improvement involves advising the young patients to stop attending several after-school
cram schools(a habit which has become a burden), requesting the mother to stop

over-possessiveness or excessive meddling, and such.

The patient is not informed thatthe visual dysfunction is the result of stress.

2.2.3

The intervention and completion of treatment
Completion of SAT therapy intervention was done after conducting one to several

interventions and confirming improvements in each of disappearance of verbal complaints,
evaluationofpsychologicalcharacteristics,

andvisualfunctionassessment.

Finally ,healing judgment was done by doctors for both groups, and treatment wascompleted when the subject was judged to be healed based on improvement of visualfunctions including corrected vision.

2.3

Method of investigation
A survey was conducted to the patients and their guardians using a self-reportquestionnaire.

In follow-up studies, subjects who were periodically visiting hospitals fornear-sightedness and similar problems even after treatment were given questionnaires
directly at the hospitals.

To the other subjects, the questionnaires were posted by mail.

The follow up survey for the medium-term prognosis study was conducted in July 2002,

International Journal of Structured Association Technique No.3

7

and that for the long-term prognosis study was implemented in July 2004.

In the current

study, “medium-term prognosis” was defined as prognosis at a time point of one year or
more after treatment, whereas “long-term prognosis” was defined as prognosis at a time
point of three years or more following treatment. The questionnaire items for patients andtheir guardians are as follows:＜ For the patients＞(1) Subjective symptoms: Higuchi (2000) and Higuchi & Munakata (2002) createdthis scale. Questionnaire items were collected from the data provided by the patients
after which an item pool was created. After consulting with two ophthalmologists andthree Orthoptists, 14 items were set after correcting inappropriate expressions. The 14
items included “Characters on the blackboard are difficult to see” and “Textbook
characters are difficult to read.” The scores ranged from: 3 (Strongly Agree), 2 (Agree); 1(Slightly Agree) and 0 (Disagree) with the total scale score ranging from 0 to 42 points.
Cronbach's α coefficient was 0.95.
(2) State-trait anxiety inventory for children (STAIC; Soga, 1983): Assuming that astate anxiety indicated a “temporary emotional state that may change depending on theconditions being experienced by the subject” and a trait anxiety a “temporary emotional
state that reflected a reaction inclination of the subject relative to the anxious stateexperience,” Spielberger (1966) created STAI and then a “State-transition anxiety
inventory for children” (STAIC). This scale is a Japanese version standardized by Soga
(1983). It consists of 20 items such as state and trait anxiety. Each item is scoredbetween one and three with three being the highest level of anxiety. Anxiety points are
distributed between 20 and 60. Only the trait anxiety scale was used this time to checkthe tendency of anxiety. Cronbach’s α coefficient was 0.90.

International Journal of Structured Association Technique No.3

8

(3) Self-esteem for children (same as above): This scale is used to measure thedegree of self-satisfaction or how highly the subject regards him- or herself. It was
created by Yoshiba & Munakata (1997) and consists of ten items with values of 0 to 10
assigned to each item. A higher score indicated higher self-esteem. Cronbach’s αcoefficient was 0.83.
(4) Self-repression for children (Yoshiba & Munakata, 1997) (same as above): The
self-repression scale is used to measure the behavioral trait indicating the patient’s
tendency to suppress his or her feelings or thoughts to avoid being disliked by others, orto avoid making things worse. This scale for children was revised by Yoshiba from thatdeveloped originally by Munakata. This scale consists of 10 items with point values
assigned to each item of two points for “Always yes,” one point for “Often yes,” and nopoints for “No” with the total score ranging from 0 to 20 points. Cronbach’s α coefficient
was 0.83. This time, a value of 0.79 was obtained.
(5)Emotional dependency for children (Yoshiba & Munakata, 1997) (same asabove): This scale is used to measure how much the relevant child expects others to takecare of him or her and level of emotional dependency. This scale measures the trait
whereby those behaviors that allow the subject to cope with the expectations of others
are adopted according to other’s evaluations, as well as that trait whereby unrealistic
expectations continue to be held, even for an unreliable person. This scale consists of ten
items with the total score between 0 and 10 points. Cronbach’s α coefficient, from whichinternal consistency was confirmed by Yoshiba, was 0.74. This time, a value of 0.71 was
obtained.
(6) Perceived Emotional Support (Yoshiba & Munakata, 1997) (same as above):This scale focuses on the perceived emotional support provided by the various social
support networks. It measures how much a child is aware that there are “people around

International Journal of Structured Association Technique No.3

9

you who support you emotionally and mentally.” This scale, originally developed by
Munakata, has been revised for children and its validity and reliability have been
confirmed. This scale consists of ten items with a total score of ten points. Four
categories include “Father”, “Mother”, “Brother” and “Friend” and the children identify
which of these they have as supporters. Each individual counts for one point. The
Cronbach’s α coefficient for children, as confirmed by Yoshiba & Munakata (1997), is
between 0.83 and 0.89. The α coefficients obtained for this sample were 0.91 for Father,
0.88 for Mother, 0.84 for Brother, and 0.81 for Friend.

＜ For the guardians＞(i) Results of eye tests done in school physical examinations(ii) Complaints of vision difficulties(iii) Causes behind the visual impairment of the child, the child’s personality, behavior,child-parent relationship, family relationships.
（ 4 items, open-ended）

For subjects who recurrence was suspected,

a visual function test

were executed.

Additionally, an interview survey of the guardians as to the causes of recurrence was
executed after verifying the guardians’ wish to consult the therapists.

2.4

Method of Analysis
The Friedmann test was used for data of three or more time points.

When awithin-group comparison showed a difference, a multiple comparison test (Wilcoxon

International Journal of Structured Association Technique No.3

10

signed-rank test with Bonferroni correction) was used, and the evaluation was done bymodifying the assessment criteria of the P value following Bonferroni correction.
Differences between groups were tested with the Mann-Whitney U test.

Furthermore,qualitative data such as verbatim records of the counseling process and verbatim recordsof the interview data were analyzed together with quantitative data.

3.

Results

3.1

Demographic Characteristics of Intervention Participants (Table 1)
In the medium-term prognosis study, 23 subjects who had been healed for one year

or more were asked to participate in the study out of which 17 subjects responded,making the valid response rate as 73.9%.

In the long-term prognosis study, 14 out of 20

subjects responded, making the response rate as 70.0% -- Table 1.
The follow-up period for the medium-term prognosis study was 21.82 ± 7.6 months
after healing, whereas that for the long-term prognosis study was 48.14 ± 7.72 months.

International Journal of Structured Association Technique No.3

11

3.2

Recurrence frequency of psychogenic visual disturbance depending on themethod of treatment
A comparison of psychogenic visual disturbance recurrence depending on themethod of treatment was conducted.

At the medium-term prognosis observation time

point, results revealed recurrence in 2 out of 7 patients (28.6％ ) in the group that
underwent conventional-type treatment.

On the other hand, in the group that received

SAT therapy, recurrence was contained to just one case out of the 10 subjects treated(10%).

However, no statistically significant difference (Pearson’s χ 2 ＝ 0.977.00, df=1,

p=0.323) was noted as the studied cases were few in number.
At the long-term prognosis observation time point, results revealed recurrence in 1
out of 5 patients of the conventional-type treatment group, and in one case, thepsychological symptoms had deteriorated and were diagnosed as symptoms ofdepression.

On the other hand, in the group that received SAT therapy, there were nocases that showed recurrence of visual disturbance, but there was one patient who was
refusing to attend school.

Again, no significant statistical difference was found as to thenumber of visual disturbance recurrence cases between the two groups (Pearson’s χ 2 ＝0.733, df=1, p=0.188).

3.3

Changes in psychological characteristics and psychotic symptoms before andafter therapeutic intervention depending on the method of treatment

1) Baseline ValueFirst, baseline values of various scale scores in the SAT intervention group andconventional-type treatment group before and after treatment were compared.

There

was no significant difference in the two groups (Table 2).

International Journal of Structured Association Technique No.3

12

Table 2.
Comparison of baseline data (before intervention) between SAT and conventional
therapy groups

Mean Score ±SD
Conventional
Therapy
SAT group

group

Scale(Min-Max)(n=10)(n=7)

Z

difference

SATIC

41.0±5.938.0±4.4

-0.64

n.s.

8.7±4.7

8.0±4.1

-0.16

n.s.

6.7±1.8

6.9±1.6

-0.11

n.s.

4.4±2.1

4.0±1.6

-0.70

n.s.

4.3±1.7

4.1±1.3

-0.16

n.s.

5.8±2.6

6.9±2.0

-0.20

n.s.

(20-60)Self-repression

Statistically(0-20)
Emotional dependency(0-10)
Self-esteem (0-10)
Percived emotional
support from Father (0-10)
Percived emotional
support from Mother (0-10)
Mann-Whitney U test

International Journal of Structured Association Technique No.3

132) Changes in psychological characteristics and psychotic symptoms before and after
therapeutic intervention depending on the method of treatment.
(i)Trait anxiety (STAIC)
Before commencing SAT treatment the score was on average 41.0±5.9 points, soonafter SAT therapy it was on average 31.9±4.1 points, at the medium-term prognosis study
time point, it was on average 32.1±9.0 points, and at the long-term prognosis study time
point, it was on average 28.3±6.3 points, showing a significant difference at the 4observation time points (Friedman, p=0.022).

Compared to before intervention, asignificant drop was seen soon after intervention (p<0.05) and at the long-term prognosis
study time point (p<0.05), and the drop of scores at the medium-term prognosis study
time point had a significant tendency (p<0.10) (Table 3-1).
Meanwhile in the conventional-type therapy cases, the score prior to treatment wason average 38.0±4.4 points, after therapy it was on average 36.7±3.1 points, at themedium-term prognosis study time point, it was on average 39.7±3.9 points, and at thelong-term prognosis study time point, it was on average 37.2±7.1 points, showing no
significant statistical difference at the 4 observation time points (Friedman, p=0.267 n.s)
(Table 3-2).

(ii)

Self repression
Before commencing SAT treatment the score was on average 8.7±4.7 points, soonafter SAT therapy it was on average 4.2±2.1 points, at the medium-term prognosis study
time point, it was on average 4.6±4.9 points, and at the long-term prognosis time point, it
was on average 3.0±2.3 points, showing a significant difference at the 4 observation time
points (Friedman, p=0.015).

Compared to before intervention, a significant drop wasseen soon after intervention (p<0.05) and at the long-term prognosis study time point

International Journal of Structured Association Technique No.3

14

(p<0.05)(Table 3-1).
In the conventional-type therapy, the score prior to treatment wason average 8.0±4.1 points, after therapy it was on average 7.6±3.9 points, at themedium-term prognosis study time point, it was on average 9.3±3.9 points, and at thelong-term prognosis study time point, it was on average 5.6±2.0 points, showing no
significant statistical difference at the 4 time points ( Friedman, p=0.3916, n.s.) (Table
3-2).

(iii)

Emotional dependency
Before commencing SAT treatment the score was on average 6.7±1.8 points, soonafter SAT therapy it was on average 4.2±1.2 points, at the medium-term prognosis study
time point, it was on average 5.2±1.9 points, and at the long-term prognosis study time
point, it was on average 4.4±2.3 points, showing a significant difference at the 4observation time points (Friedman, p=0.0415).

Compared to before intervention, asignificant drop was seen soon after intervention (p<0.05).

In medium-term prognosis

and long-term prognosis, even though there was a drop of the average scores comparedto that before intervention, there was no significant statistical difference (Table 3-1).
In the conventional-type therapy, the score prior to treatment was on average
6.9±1.6 points, after therapy it was on average 6.3±1.7 points, at the medium-term
prognosis study time point, it was on average 7.4±1.4 points, and at the long-term
prognosis study time point, it was on average 7.4±2.7 points, showing no significant
statistical difference (Friedman, p=0.3033 n.s) (Table 3-2).

International Journal of Structured Association Technique No.3

15

Table ３-1

SATIC
Self repressioninterpersonal dependency

Longitudinal observation on psychological characteristics in SAT
therapy group
beforeintervention

afterFriedma Statisticall
interventio 2 years
4 years n χ2＝ynfollow-up follow-up(df)
difference

41.0(5.9)a31.9(4.1)b8.7(4.7)a6.7(1.8)a4.2(2.1)b4.2(1.2)b

14.6
(3)

a>b, a>d*a>b†3.0(2.3)d

10.5
(3)

a>b,d*

4.4(2.3)d

8.2
(3)

a>b*
a>b* a>d†32.1(9.0)c 28.3(6.3)d4.6(4.9)c
5.2(1.9)c

Self esteem

4.4(2.1)a8.9(1.2)b6.4(2.7)c

6.9(1.1)d

14.2
(3)

perceived emotional support from
Father4.3(1.7)a8.3(1.1)b5.2(4.1)c

6.0(2.8)d

7.3
(3)

a>b*

9.1(1.5)d9.6(3)a>b* ,a>c†

perceived emotional support fromMother5.8(2.6)a9.6(0.5)b9.0(2.1)cFriedman rank sum test
† Significant at P<.08 Wilcoxon paired signed rank testwith Bonferroni adjustment ( Post hoc test)* Significant at P<.05 Wilcoxon paired signed rank test with Bonferroni adjustment ( Post hoc test)** Significant at P<.01 Wilcoxon paired signed rank test with Bonferroni adjustment ( Post hoc test)

International Journal of Structured Association Technique No.3

16

Table 3-2

Longitudinal observation on psychological characteristics inconventional therapy group

beforeintervin
tion

After
intervention

2 yearsfollo
w-up

4 years
follo
w-up

Friedman
χ2
＝
(df)
4.8

SATIC

38.0(4.4)

36.7(3.1)

39.7(3.9)

37.2(7.1)
4.0

Self repression

8.0(4.1)

7.6(3.9)9.3(3.9)

5.6(2.0)
3.6

Emotional dependency

6.9(1.6)

6.3(1.7)

7.4(1.4)

7.4(2.7)

Self esteem

4.0(1.6)

4.4(2.0)

3.7(3.4)

4.8(3.4)

Perceived emotional support from
Father4.1(1.3)

4.9(1.8)

6.3(3.8)

3.8(3.2)

0.6

Perceived emotional support fromMother1.6
1.3
6.9(2.0)

6.5(2.1)

6.5(4.0)

7.8(3.9)

Statisticallydiffere
nce

(3)

n.s.

(3)

n.s.

(3)

n.s.

(3)

n.s.

(3)

n.s.

(3)

n.s.

Friedman rank sum test(iv)

Self‐esteem
Before commencing SAT treatment the score was on average 4. 4±2.1 points, soonafter SAT therapy it was on average 8. 9±1.2 points, at the medium-term prognosis study
time point, it was on average 6. 4±2.7 points, and at the long-term prognosis study time
point, it was on average 6.9±1.1 points, showing a significant difference at the 4observation time points (Friedman, p=0.027).

Compared to before intervention, asignificant rise was seen soon after intervention (p<0.05).

International Journal of Structured Association Technique No.3

In long-term prognosis

17

(p<0.07), a rise with a significant statistical tendency was seen (Table 3-1).
In the conventional-type therapy, the score prior to treatment was on average
4.0±1.6 points, after therapy it was on average 4.4±2.0 points, at the medium-term
prognosis study time point, it was on average 3.7±3.4 points, and at the long-term
prognosis study time point, it was on average 4.8±3.4 points, showing no significant
statistical difference (Friedman, p=0.8866, n.s) (Table 3-2).

(v) Perceived Emotional Support from father
Perceived Emotional Support was on average 4.3±1.7 points before commencing
SAT treatment, soon after SAT therapy it was on average 8.3±1.1 points, at themedium-term prognosis study time point, it was on average 5.2±4.1 points, and at thelong-term prognosis study time point, it was on average 6.0±2.8 points, with a significant
tendency at the 4 observation time points (Friedman, p=0.0638).

Compared to before

intervention, the score following intervention was significantly high (p<0.05) (Table 3-1).
In the conventional-type therapy, the score prior to treatment was on average 4.1±1.3
points, after therapy it was on average 4.9±1.8 points, at the medium-term prognosis
study time point, it was on average 6.3±3.8 points, and at the long-term prognosis study
time point, it was on average 3.8±3.2 points, showing no significant statistical difference(Friedman, p=0.6525) (Table 3-2).

(vi)

Perceived Emotional Support from mother
Perceived Emotional Support from mother was on average 5.8±2.6 points before

commencing SAT treatment, soon after SAT therapy it was on average 9.6±0.5 points, atthe medium-term prognosis study time point, it was on average 9.0±2.1 points, and at thelong-term prognosis study time point, it was on average 9.1±1.5 points, showing aInternational Journal of Structured Association Technique No.3

18

significant change at the 4 observation time points (Friedman, p=0.0222).

Compared tobefore intervention, the score following intervention was significantly high (p<0.05).
Even at medium-term prognosis, a rise was seen although with a significant tendency(p<0.10）（ Table 3-1） .
In the conventional-type therapy, the score prior to treatment was on average
6.9±2.0 points, after therapy it was on average 6.5±2.1 points, at the medium-term
prognosis study time point, it was on average 6.5±4.0points, and at the long-term
prognosis study time point, it was on average 7.8±3.9points, showing no significant
statistical difference at the 4 observation time points (Friedman, p=0.7379) (Table 3-2).

4.3.5

Analysis of causes behind recurrence in recurrent cases (Table 4)
Features of changes in psychological characteristics in the 3 recurrent cases seenat the medium-term prognosis study time point were analyzed.

Case A and B had

received conventional therapy, and Case C had received SAT therapy.

Recurrence wasconfirmed in Case A even at the time long-term prognosis study time point.
(i) Recurrent cases in the SAT-therapy group (C) – Table 4-1
After intervention, the scores of SATIC, self-suppressive behavioral characteristics
and interpersonal-dependent behavioral characteristics showed a drop, but there was asignificant rise in the scores at the time of recurrence (medium-term prognosis study time
point).

After that, vision improved by SAT intervention and at the long-term prognosis

study time point all the scores had remarkably improved.
The degree of awareness of emotional support from father and mother showed an
improvement following intervention, but at the time of recurrence (medium-term prognosis
study time point), a significant drop in scores was observed.

The scores then improvedat the long-term prognosis study time point.

International Journal of Structured Association Technique No.3

19

International Journal of Structured Association Technique No.3

20

Table 4-1. Features of psychological characteristics in the recurrent cases in the SAT-therapy group

Scale(Min-Max)

Case

SATIC(20-60)

C

Self repression (0-20)

CInterpersonal dependency (0-10)

C

Self esteem (0-10)

C

Perceived emotional support from Father (0-10)

Perceived emotional support from Mother (0-10)

beforeintervention

Afterintervention

2 years
follow-up

4 years
follow-up

36

32

49↑

34

6

4

16↑

6

8

5

8↑

4

2

8

2↓

8

3

10

4↓

7

4

9

4↓

9

C

C

International Journal of Structured Association Technique No.3

21

Table 4-2. Features of psychological characteristics in the recurrent cases in Conventional therapy group

Scale(Min-Max)

Case

SATIC(20-60)

A
B

Self repression(0-20)

A
B

Interpersonal dependency (0-10)

A
B

Self esteem (0-10)

A
B

Perceived emotional support from Father (0-10)

A
B

Perceived emotional support from Mother (0-10)

AB

beforeinterve
ntion

After
intervention

2 years
followup

4 years
followup

42

40→

41→

34↓

32

31→

42↑

48↑

3

3→

11↑

9↑

7

7→

5↓

6

6

5→

9↑

7

6

5→

7↑

10

4

4→

7↑

5

3

3→

0↓

0↓

3

3→

0↓

0

5

5→

10↓

1

6

8↑

3↓

2↓

5

6→

0↓

10↑

(ii) Recurrent cases in the conventional-therapy group – Table 4-2
In the 2 recurrent cases of the conventional-therapy group, there was no change inscores, and a high degree of anxiety continued until the time of recurrence (medium-term
prognosis study time point).

In Case A where recurrence was confirmed at the time

long-term prognosis study time point, the anxiety had become even stronger.

International Journal of Structured Association Technique No.3

Degree of22self-repression showed no change in Case B from before treatment to long-term
prognosis study time point, whereas a rise in the score was seen for Case A at time ofrecurrence.
Scores of interpersonal dependence-type behavioral characteristics hardly changed
in both cases even after therapy, a rise was seen at the time of recurrence (medium-term
prognosis study time point), which continued to be high even at the long-term prognosis
study time point.
Self-esteem scores showed no change before and after therapy, and continued to be
low, showing a further decline at the follow-up study time point.
Perceived Emotional Support from father showed no change following therapy, andalthough a drop was seen in one case at the follow-up study time point, in the other case,there was a rise in the score.

As for the Perceived Emotional Support from mother, aslight rise in scores was observed in both cases, but at the time of recurrence(medium-term prognosis study time point), the scores had sharply declined.

In Case A

where a further decline in vision was seen at long-term prognosis, this score showed anincrease, but in Case B, there was a further decline.

3)

Narrative evaluation of recurrence causes recognized by the patient himself andparents in recurrent cases
Inquiries were made as to causes that influenced recurrence in the 3 recurrent
cases.

There were important causes such as the way love was expressed, lack ofcommunication within the family, etc.
4.

Discussion
In the present study, recurrence was seen in 2 out of 7 patients (28.6％ ) in thegroup that underwent conventional therapy, and in 1 out of 10 patients (10.0％ ) in theInternational Journal of Structured Association Technique No.3

23

group that underwent SAT therapy, at the medium-term prognosis observation time point.
At the long-term prognosis observation time point, recurrence was seen in 1 out of 5
patients (20%) in the conventional-type treatment group, whereas in the SAT therapy
group, no visual disturbance recurrence was found in any of the patients (0 out of 9, 0%).
Up to now, reports on PVD prognosis following therapy have described non-healing or
recurrence in 7 out of 15 patients (46.7%) as reported by Rada et al. 22) from the field ofclinical psychiatry; in 8 out of 19 patients (43.1%) as reported by Abe et al. from the fieldof ophthalmology; in 4 out of 14 patients (28.6%)) as reported by Sletterberg et al. 7) ; andin 1 out of 23 patients (4.3%) as reported by Catalano et al. 23) . Even when these pastreports and the present study’s results for conventional therapy are compared, thelong-term prognosis following SAT therapy was the best after the Catalano report.
Catalano et al. 23) report that 35% of the cases showed an improvement within 24 hours
and 61% showed an improvement within a month by merely a guarantee that the patient
will be “definitely cured”.

In contrast, the subjects of present study’s SAT therapy

included many cases that had showed no response even to treatment spanning a few
months to one year or more after being diagnosed with PVD.

Even though a simple

comparison is not possible, SAT therapy effects are thought to be good considering thesedifferences in severity of the cases studied.
Mochizuki et al. 24) divided into two groups 42 patients who has been diagnosed ashaving conversion disorders by DSM-III-R based on decreased vision as the main
complaint.

The two groups were improved group and protracted group.

Mochizuki etal. 24) reported that children who refused to attend school were significantly higher in the
improved group.

In the present study, although there was one child who refused goingto school after SAT therapy, going to school became possible shortly after the childhimself chose to undergo SAT therapy and when the problems were solved after theInternational Journal of Structured Association Technique No.3

24

intervention.

This showed that symptom shifts to other somatizations and behavioral

symptoms is hardly seen in SAT therapy intervention, and that resolution of underlying
issues is urged.
There are extremely few reports relating to long-term prognosis of PVD.
Yokoyama 10) observed long-term prognosis for 2 PVD cases and reported a psychologicalmechanism that mental swings of adolescence, namely sibling conflicts was the cause.
The present study elucidated a long-term prognosis of PVD (4 years in average after
healing) for the first time in a positive study with a control group and based on detailed
data on visual functions and psychological characteristics following active intervention.
This

study

revealed

that

(i)

trait

anxiety,

self-suppression,andinterpersonal-dependence that decreased following SAT therapy remained low even at thelong-term prognosis observation time-point, and (ii) self value and degree of awarenessof mother’s emotional support that improved following SAT therapy remained high even at
the long-term prognosis observation time-point, although there was a slight drop.
Detailed evaluation of each psychological characteristic showed that, first, PVD has acharacteristic low self-value, which is improved after SAT intervention.

Self-assessmentand feelings of self-respect which are similar to self-value are said to arise from the ageof eight 25) .

This is the stage around which self-consciousness develops, enhancing aninterest in internal matters.

Incidentally, this period around 8 years of age overlaps withtime when symptoms of psychogenic visual disturbances peak.

Self-assessment at thisstage depends on the assessment of others by significant others (generally, the mother).
C. Rogers describes that children perceive themselves through clarification ofself-concepts within interactions with significant others, and require positive assessment
from significant others 26) .

It is thought that self-images and self-concepts getdetermined by assessments of those around from early childhood, and self-confidence isInternational Journal of Structured Association Technique No.3

25

created and acted out via having a positive image of oneself.

Having a low self-value ata time when the foundation of self- assessment is being completed, is thought to create
defects in self-confidence and increase uneasiness when taking various actions, because
the child always worries about other people’s opinions.

Therefore, psychologicalinterventions at this stage that focus on self-image enhancement are extremely important.
In SAT therapy, latent traumatic memories such as sensation images in the fetal stage
or early childhood were approached from problems recognized at the present time, andimage conversion was conducted to satisfy unfulfilled internal demands of the mind andunresolved emotions associated with the trauma.

To mention, re-learning of perception

and behavior based on positive images was encouraged.

Munakata has described that“dangers to survival experienced in infancy and birth are unconsciously played back 27)”.
There are also reports that causes of certain mental and physical problems may lie in the
fetal period, and experiences made during this fetal period and at birth have a huge
influence on the life thereafter 28) .

By trying to approach traumatic memories that thepatient is not aware of, SAT intervention is thought to have made it possible to transform
various images of oneself and one’s surroundings.
The following may explain the low self-suppression and interpersonal-dependence.
What is behind strong interpersonal dependence are non-fulfillment of needs and desires
to feel affection such as “not being understood”, “not being able to emotionally depend on
someone”. High -suppression has the tendency to suppress ones thoughts and feelings tosuit the expectations of those around.

Negative latescent image memories such as fearof being abandoned, self denial, and loneliness are behind the patient being forced to
become independent, giving up the need to emotionally depend on others.

In SAT

therapy intervention, real desires within the heart may be fulfilled due to the formation of
the self-image that the patient is treasured by his/her parents, thus decreasing theInternational Journal of Structured Association Technique No.3

26

dependence and self-suppression.
Although a rise in the degree of awareness of the mother’s emotional support wasseen the SAT therapy group, this degree was low in all recurrent cases at the recurrence
point.

Deterioration of relationships with family and parents is thought to deteriorate theself-image along with the decrease of the feeling of having emotional support.

This isthought to lead to stronger stress responses, and cause, as a physical response, theonset of visual disturbance recurrence.

Wynick et al. 29) showed by analyzing PVD

children’s assessments of their mothers, that these children thought that while the motherwas very loving and receptive towards him or herself, she was also dominating andmeddlesome.

The improvement of the degree of awareness of the mother’s emotional

support through SAT therapy can be presumed to have been the result of an improvementin the awareness of support from a significant other due to the decrease of the child’s
degree of dependence.

However, in future, it would be necessary to conduct SAT

therapy taking the influence of the family environment surrounding the PVD child into
consideration.
Causes of PVD recurrence had, as intrapersonal factors, the features of (i) highanxiety, (ii) high self suppression and interpersonal dependency, and (iii) low self-value
and low degree of awareness of the parents’ emotional support.

In cases in whom an

improvement was seen after SAT intervention, the state of psychological characteristics
were more or less maintained from the time soon after intervention, whereas recurrent
cases showed a deterioration of psychological characteristics that once improved at thetime of intervention. Taking into view situations where the gap between image scenarios
created for SAT therapy and the actual images are too big, in order for the patient toconvert the parental image and for that image to become established, SAT therapy
currently considers it vital that (i) the parents themselves grow and accept psychologicalInternational Journal of Structured Association Technique No.3

27

interventions to change the personality so that they would become able to unconditionallyaccept the child, and(ii) the child lives separated from the parents for a while 30) .

Even in the present recurrence, the improved parental image may have become bad
again because the improved image was considerably different to the actual.
Turgay 31) gives the following as factors that correlate with good therapeuticachievements for conversion disorders in childhood and adolescence: (i) being a juvenile,(ii) having a healthy personality, (iii) having healthy family functions, and (iv) the family
understanding the psychological features of the disorder.

The present result alsosuggests that even in the PVD healing process, healthy psychological characteristics
equivalent to Turgey’s “healthy personality”, in other words personality development, andthe surrounding environment that “the family understanding the psychological features ofthe disorder” are highly important.
The present study reveals that to treat PVD, counseling of the patient and providing
guidance for the mother are effective in most of the cases.

However, analysis ofrecurrent cases teaches the necessity for the following improvements.

Likelihood ofrecurrence is highly increased when the mother’s level of anxiety is high, and theaffection of “unconditionally accepting the child” is low.

In such cases, it is vital thatfirst the mother herself becomes emotionally stable to accept the child under any
circumstance.

Therefore, the authors believe that simultaneous SAT therapy

intervention for the mother would lead to the prevention of recurrence and even solutionof family issues that are appearing as a physical reaction in the child.
The sorting into each of the intervention groups done in the current study is nothomogeneous.

For example, the SAT group included cases in whom healing could not

be seen even after several months, and too few cases were studied.

Therefore, there

still issues remaining for strict evaluation of SAT intervention group and conventional

International Journal of Structured Association Technique No.3

28

therapy intervention group.

4.2

Conclusion
Effects of psychological intervention by SAT therapy were observed for a long

duration assessing recurrence rate, behavioral characteristics
psychological symptoms.
(i)and changes in

As a result, the following findings were obtained:

Recurrent numbers for each method of therapy was 2 out of 7 patients (28.6％ ) in
the conventional-type therapy group at the medium-term prognosis observation
time point, whereas it was one case out of the 10 subjects (10.0%) in the SAT
therapy group, although there was no statistically significant difference.

At thelong-term prognosis observation time point, visual disturbance recurrence wasseen in 1 out of 5 patients in the conventional-type therapy group, whereas
recurrence was not seen in the SAT therapy group.

Therefore, in both groups asignificant difference in visual disturbance recurrence was not seen even at thelong-term prognosis observation time point.
(ii)

In the SAT therapy intervention group, scores of self-repression, emotional
dependency and trait anxiety that improved soon after intervention remained loweven though there was a slight increase at the long-term prognosis observation
time-point. Similarly, scores of self value and degree of awareness of mother’semotional support similarly remained high, even though there was a slight drop.
On the other hand, scores of self-repression, self-esteem, trait anxiety, andperceived emotional support were hardly changed in the conventional-therapy
group.

(iii)

In PVD recurrent cases, it was confirmed that anxiety, self- Self-repression, andInternational Journal of Structured Association Technique No.3

29

emotional dependency are high even though an improvement is temporarily seen,and self-value and degree of awareness of mother’s emotional support are low,
thus accompanying a change in psychological characteristics.

The above results suggest that since psychological conflicts are behind the onset of PVD,
therapy should not focus on resolving superficial issues such as visual disturbance, butshould involve psychological interventions that encourage finding solutions to those
psychological conflicts.

International Journal of Structured Association Technique No.3

30

References
1） Yokoyama, H. (1999). Psychogenic visual disturbance. Ophthalmology in Japan, 70(10), 1227-1231.
2) Okuyama N, Kawakatsu S, Wada T, Komatani A et al: Occipital hypo-perfusion in apatient with psychogenic visual disturbance.

Psychiatry Research Neuroimaging

114:163-168,2002
3) Hisako Watanabe: Hysteria（ dissociative disorder）. Journal of pediatric practice63（ 10） :1508-1514,2000
4） Bass C and Benjamin S: The management of chronic somatization. British Journal of
Psychiatry 162: 472-480,1993
5 ） Noriko Higuchi, Tsunetsugu Munakata, Sayuri Hashimoto and Hirohiko Higuchi:
Psychological Characteristics of Children with Psychogenic Visual Disturbance.
Journal of the eye.21:999-1004,2004.
6） Masatoshi Tanaka: Perspectives of Stress-From a biological standpoint. Shinryonaika
2:93-99,1998.
7) Sletterberg O, Berteisen T, Hovding G: The prognosis of patients with hysterical visual
impairment. Acta Ophthalmol 67(2):159-163,1989
8) Kazuhiko Abe: Treatment of psychogenic vision impairment in children. Rinsho Seishin
Igaku 16(10):1443-1448， 1987
9) Minoru Okamoto, Masayasu Watanabe, Hidetomi Watanabe et al.:disorders in adolescence. Ganka

Psychogenic eye

26： 147-152， 1984

10) Naohiro Yokoyama: Psychogenic visual disturbances understood by long-term
observation cases. Gannka rinsho ihou 93(5):790-793,1999
11) Yoshihisa Oguchi: Psychogenic visual disturbances in school-age children. Ganka
26:139-145,1984.

International Journal of Structured Association Technique No.3

3112) Junko Tozawa and Hideyuki Unuma: Pathology and treatment strategies in
Psychogenic visual disturbances- focusing on the mother-child relationship.
Ganrini2（ 5）： 658−664， 1998

13) Tsunetsugu Munakata: Chapter 1, Practice counseling based on structuralized
association technique.

Counselling Therapy and Health, Editorial Supervisor:

Tsunetsugu Munakata: Kaneko Shobo, Tokyo. 3-26， 2004
14) Clinical psychology handbook for mental clinicians- edited by Keigo Okonogi, Chikako
Fukatsu, and Yu Ohno, revised edition 42, Sogensha, Tokyo 2005
15) Van den Bergh BR, Mennes M, Oosterlaan J, Stevens V, Stiers P, Marcoen A and
Lagae L.:High antenatal maternal anxiety is related to impulsivity duringperformance of cognitive tasks in 14- and 15-year-olds.Neurosci Biobehav Rev.
29(2):259-69,2005
16) Van den Bergh BR and Marcoen A.:High antenatal maternal anxiety is related to
ADHD symptoms, externalizing problems, and anxiety in 8- and 9-year-olds. Child
Dev. 75(4):1085-97, 200417) Van den Bergh BR, Mulder EJ, Mennes M, and Glover V:Antenatal maternal anxiety
and stress and the neurobehavioural development of the fetus and child: links andpossible mechanisms. A review. Neurosci Biobehav Rev. 29(2):237-58,2005
18) Sheikh AA: Imagination and healing.

Amityville, NY ,Baywood,1984

19) Noriko Higuchi ： Research on SAT image therapy for psychogenic visual
disturbances-centered on a follow up study spanning more than a year. 2002 Masterthesis collection of the University of Tsukuba School of Comprehensive Human
Sciences， 2003.
20) Soga, S. (1983): Study of STAIC standardization Japanese edition. PsychologicalResearch, 54, 215-221.

International Journal of Structured Association Technique No.3

3221) Yoshiba, K., & Munakata, K. Development of psychological health-related scales forchildren. The Japan Association of Mental Health Sociology Annual Report, 7： 29− 35， 199722) Rada RT, Meyer GG, and Kellner R: Visual conversion reaction in children and adults.
J of Nerv & Ment Dis 166 (8):580-587,1978
23) Catalano RA, Simon JW, Krohel GB, Rosenberg PN: Functional Visual loss in children.
Ophthalmology 93(2):385-390,1986
24) Hiromi Mochizuki， et al： Pathological Images of psychogenic visual disturbances- acomparative analysis of an improved group and persisting group.

Abstracts of the

38 th Annual Meeting of The Japanese Society for Child and Adolescent Psychiatry,
157， 1997
25） Christoph Andre and Francois Lelord: Psychology of Self Assesment; 4th Edition,
Kinokuniya Shoten, Tokyo, 94， 2001.
26) Morio Saji and Kiichiro Iinaga: Rogers client oriented therapy, yuhikakushinsho, 1stedition, 15th print， 1998
27) Tsunetsugu Munetaka: Health Counselling Evolution Theory, 3 rd Self-care support
viewed from a stress-management standpoint.

Health Councelling 5（ 3）: 49-54,

200228) Michael G and Marie G，translated by Yoko Huey: The Fetus Speaks- The womb is thecradle of the soul: cyoubunnsya， 1999
29) Wynick S, et al: Psychogenic visual disorders in children-Perspectives fromadolescence. Journal of Child psychology & Psychiatry & Allied Disciplines 38(3):375-379,1997
30) Tsunetsugu

Munakata： SAT Image Therapy for the family with seclusive young

people. Psychosomatic Medicine 42(1)： 37-46， 2002

International Journal of Structured Association Technique No.3

3331) Turgay, A: Treatment outcome of children and adolescents with conversion disorder.
Can J Psychiatry 35 :585-589,1990

International Journal of Structured Association Technique No.3

34