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ABSTRaCT Conversion disorder is rare, but when it affects a young woman on the verge of adulthood, it can be devastating. The intent of this article is to encourage others by describing the success that psychiatry and alternative medicine can offer to patients with conversion disorder and to emphasize the value of nursing as a part of that team. This article will explore the attitude change in both staff and patient that was needed to achieve the ultimate goal of wellness.

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A Clinical and Holistic Approach

Sandra L. Tocchio, RN

his article is about the journey of a patient with conversion disorder and how a team approach and alternative medicine, in conjunction with conventional psychiatry, helped alleviate her symptoms. It is about staff who learned to listen to their patients and recognize the importance of nursing within the treatment team. It is also about the staffs journey from having predetermined judgments and concrete standards of care to being more open to alternative therapies and willing to accept the strong connection between mind and body. It is about how this patient with conversion disorder taught us that, given the right environment, time, and skills, patients can play a large role in healing themselves. She taught us to have hope and to see there can be positive outcomes in psychiatric nursing. It is about these two experiences joining on one path to wellness. BaCKGROUnD The news of this patients pending arrival quickly made its way through the staff. We were admitting a 19-year-old woman with a diagnosis of conversion disorder. She had been an active, vibrant, high-achieving adolescent with excellent grades

in school, but now she would at times be blind or unable to ambulate and would vomit after every meal. We were informed she could occasionally be paralyzed from the mouth down and would have multiple seizures every day. This had been her plight and her parents nightmare for the past 2 years. The staffs rst reaction was, What are they thinking? How can we care for someone like this? Typically, our patients are adults who can walk and complete their own activities of daily living. This patient had already experienced multiple hospitalizations. We were assured she had been medically evaluated at some of the best facilities, including an extensive neurological examination that indicated her seizures were not neurologically based but pseudoseizures. Despite the good news of the medical clearance, this patient had at times needed intravenous therapy and even nasalgastric tube feedings, so we would have to monitor her closely. She had an around-the-clock caregiver at her home to meet her needs. COnVERSIOn DISORDER Conversion disorder falls under the broader heading of somatoform disorders. The common features of these disorders are the occurrence

of physical symptoms that are not explained by a medical or neurological condition or by a substance abuse problem. The symptoms must cause signicant distress or physical impairment (Conversion Disorder, 2005). According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) (American Psychiatric Association [APA], 2000), conversion disorder is a psychological disorder in which the essential feature is the presence of symptoms that affect voluntary motor or sensory function. It is not diagnosed if the symptoms are caused by a belief in a culturally sanctioned behavior or if the patients only symptoms are related to pain or sexual dysfunction. Although conversion disorder is a psychiatric disorder, it is rarely seen by psychiatrists. Because the symptoms appear neurological, a neurologist or primary care physician is usually the rst to be consulted. Once a medical reason has been ruled out, these patients are referred to a psychiatrist. The symptoms of conversion disorder can include a loss of senses, such as being blind or deaf. Paralysis can occur, but it is usually in one leg or arm, and seizures are simulated and usually occur without incontinence, 43

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cyanosis, or tongue biting. An electroencephalogram would be negative. Often, the symptoms are inconsistent and do not follow the normal nerve pathways. The symptoms are different from actual physical paralysis in that there is muscle tone and reex. A hand could be numb from the wrist down or a limb could move while the patient was asleep or under hypnosis. Electromyograms would be normal. All physical possibilities for the symptoms

n.d.). Although this is necessary, it can be costly. The Encyclopedia of Mental Disorders estimates the cost at $20 billion, not including missed work and disability payments (Conversion Disorder, n.d.). The DSM-IV-TR (APA, 2000) states that 3% of those referred to outpatient mental health clinics and 1% to 14% of medical-surgical inpatients have conversion disorder. One study stated that these symptoms are rare in Western countries and re-

Conversion disorder usually begins in adolescence or early adulthood but can be seen up to age 35.

after psychiatric treatment began. This is an unusually long length of stay on an inpatient unit, and the familys insurance company determined this level of care was not medically necessary. It would not approve payment for her extended hospitalization, but fortunately, her parents had the resources to pay for the care. After the patients discharge and recovery, her family appealed the insurance companys decision and was awarded reimbursement for the cost of her treatment. Caution has been advised regarding discharging these patients too early. Marshall et al. (2008) suggested making sure the treatments are working and the symptoms are resolved before allowing patients to return home. POSSIBlE CaUSES The cause of conversion disorder is not clearly understood, but the term conversion suggests that repressed memories, trauma, or stress may be converted to physical symptoms to avoid stressful events in the patients life. Some believe it is a kind of dissociation and speculate whether there could be a disconnection or separation of the normal sense of self from the physical body (Conversion Disorder, 2005). Patients with conversion disorder may have difculty handling a large amount of stress. With the help of brain imaging, researchers are examining how sensory stimuli are processed in the brain. If the circuits that are in control receive false information, it could cause the voluntary muscles to malfunction (Conversion Disorder, 2005). Reduced blood ow in the subcortical structures were found when vibrations were applied to the affected limb. Hypofunctioning of the dominant hemisphere may also be a cause. Studies suggest that complex brain mechanisms JPNOnLInE.COM

must be explored and ruled out (APA, 2000). At this time, pseudoseizures are classied separately from dissociative disorders, but because of their similarity, some believe they should be grouped together ( Sar , Aky z, K Kundak i, Kiziltan , & Dogan4 4 , 2004). InCIDEnCE anD PREValEnCE The prevalence of conversion disorder is varied but ranges from 11 to 300 cases per 100,000 people (Powsner & Dufel, 2009). According to the Encyclopedia of Mental Disorders, conversion disorder is a major reason for patients to see their primary care physician (Conversion Disorder, n.d.). One study estimated that 25% to 75% of ofce visits involved some psychological stress that took the form of physical symptoms (Conversion Disorder, n.d.). Another study estimated that at least 10% of all diagnostic tests are ordered for patients who have no other evidence of physical illness (Conversion Disorder, 44

ported in higher rates in Turkey (Akdemir & Unal, 2006). Conversion disorder usually begins in adolescence or early adulthood but can be seen up to age 35. It is rare in children younger than age 10 (Powsner & Dufel, 2009). Regardless of when the disorder begins, it is important to know that these symptoms are not produced intentionally and are very real and distressing to the patient. Conversion disorder is more prevalent in women compared with men (2:1 to 10:1) (Marshall, Landau, Carroll, & Schwieters, 2008). In a study in India, the higher percentage of girls was because they grew up in a more inhibited emotional environment and were shown less attention than boys (Bisht, Sankhyan, Kaushal, Sharma, & Grover, 2008). The onset is usually acute, as it was in our patients case, when she was recovering from a viral illness. In hospitalized patients, symptoms may resolve within 2 weeks, but in our patients case, remission occurred 2 months

are involved in preventing normal cortical activity. Neurobiological research is ongoing and may lead to more effective therapy (Aybek, Kanaan, & David, 2008). Our staff has cared for many patients, and some have had the diagnosis of conversion disorder. Each one has had a unique story, behaviors, and symptoms. Some patients have been more challenging than others; some more memorable. This patient was both, but also someone we would never forget. InDIVIDUal EXaMPlE: TERESa On the day of admission, Teresa (pseudonym) rolled onto our unit in her special wheelchair, which had no hand-driven mechanisms because she was not able to use them. She was a pale, anxious, slightly depressed, frail girl, propped up in her chair by a stuffed animal and pillow. One of her eyes contained a black contact lens to help her focus and see better when her eyes were working at all. After giving Teresa a tour of the unit, we showed her to her room. During the admission process, she assured us she was not here for any psychological problems. She was here for medical reasons only. The beginning of treatment can be difcult for the physician, staff, and patient because the patient is convinced the symptoms are medical in nature and is looking for a medical diagnosis and cure. Even with the assurance of her extensive medical evaluation, it was impossible for Teresa to accept that there was nothing physically wrong with her. That is the reason a trusting relationship between the patient and the treatment team, along with consistent staff, is essential. Teresa appeared to accept her horric symptoms and reported

them in a matter-of-fact way. She would atly tell us, If you move me, I will have a seizure or I cant talk now; I am losing my ability to speak. If we suggested she take a shower or do another task, she would say, I will do it later; I am blind now. Tired and weak after her tour, Teresa was ready to try another hospital bed. She sat limply in her wheelchair. It was difcult for us to accept that she would unexpectedly become paralyzed or limp. She was slight in size, so we thought we could transfer her with minimal staff assistance. Teresa tried to tell us this would provoke a seizure, but we thought we knew best and lifted her as planned. The convulsing and quivering motion she displayed and the sudden collapse of her body made her dead weight in our arms. She felt like 1,000 pounds, and we had no choice but to lower her to the oor. The nurse manager, who was there to help with the transfer, slumped to the oor with her and sat cradling her, rocking her and calmly telling her that together we would all learn the best way to care for her. As the cards, family photographs, and get well wishes took over the walls of her room, our determination to x her began to take over our focus on the unit. We were constantly updating her care plan. It is hard to imagine the amount of stress Teresa and her family must have felt while enduring such terrible symptoms. Reassurance was high on our care plan list. We tried to provide consistent staff to build a strong relationship with Teresa. We would let her know we did not think she was crazy but instead reinforced that she had a recognized illness and would educate her about that disorder. We monitored her intake and output and her laboratory val-

ues. Laxatives were administered daily to counteract the effects of bed rest. Passive range of motion was performed to help with the foot drop that was already occurring. Nutritious meals, along with goodies from home, were provided when she could tolerate them. Showers were scheduled by Teresa at the time of day she felt she was the strongest. We protected her during her seizures and carefully assessed her needs when she was unable to speak. We always sought to relieve any anxiety she might have and often found that simply sitting in her room, without conversing, was helpful. We reassured her that we knew her symptoms were real, despite the lack of a medical diagnosis. We reinforced that she did not have a neurological disorder and her symptoms could improve spontaneously. During the daily rounds with the physician, staff, and case manager, and when her parents came for weekly meetings and visits, they were given the same reassurance. TREaTMEnT anD InTERVEnTIOnS No specic pharmacological therapy is available for conversion disorder, but some research has recommended an anxiolytic or antidepressant agent (Oyama, Paltoo, & Greengold, 2007). Teresa had a small dosage of lorazepam (Ativan) available if she needed it for anxiety. Anxiety can be an underlying issue with this disorder, but it appears to be suppressed by the patient, and Teresa rarely needed any of the medication. An antidepressant agent was also added. Not only can depression be a factor in conversion disorder, but the circumstances in which the patients nd themselves can be depressing. Teresa showed no signicant change in her level of depression or anxiety with the 45

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addition of the medications and experienced no side effects. Teresa, the physician, and the treatment team agreed that for the initial phase of her psychophysical assessment, Teresa would follow the unit protocol. Her vital signs would be measured in the treatment room. Medications would follow at the medication window. It was believed that being out of her room would decrease Teresas isolation and emphasize that it was not a medical hospital. Teresa would use the call light for emergencies only or ask the checks person to provide for her needs to foster independence. She was to eat at least one meal in the dining room or at least sitting up in the day room. This was not only for the proper digestion of food but also to de-emphasize any relationship to a physical illness. Her cell phone would be allowed only at the usual unit times. Her iPod, DVD player, and movies could be kept in her room, but many worried she could be living in a fantasy world by watching the ction movies she liked. We tried to provide support and acceptance for her very real fears, symptoms, and difculties while staying within the unit norms. Teresa was asked to attend two groups of her choice daily. Giving her some control was important. The groups would help encourage socialization. We also used distraction to try to keep her out of her room for periods of time. She was asked to participate in art therapy so she could express her feelings creatively and nonverbally in a safe environment. Everyone agreed that encouraging words such as, Teresa, you can do it! or Great job! would motivate her and give her the condence to keep food down or partially bear weight or help words to ow when her voice was paralyzed. 46

We knew this business. We knew the mind, this mental health work, and we knew we could make things better for her or help her come around to make things better for herself. However, all of this seemed to have the opposite effect on Teresa. The harder we tried to x her, the worse things became. She remained limp, exhausted, nauseous, and withdrawn, and now apologetic that she was not getting better. THERaPEUTIC CHallEnGES As a staff team, our upbeat attitudes were turning to frustration. We were failing. Teresa was teaching us how hard it is when you fail at the things you usually just know how to do. Teresa feared another treatment failure as well, and our words of praise were terrifying to her. She felt she would let us or her parents down if she did not achieve the expectations we had for her. So we tried to look at things differently. Again and again, we rewrote her care plan. By the third week, we used new language. A smile or a Yeah! would replace our previously intense You can do it! Her episodes of shaking were referred to as events, avoiding all of the meanings attached to the word seizure. One study suggested using the term non-epileptic seizure so the patient is assured the team is still aware the symptoms are real (Stonnington, Barry, & Fisher, 2006). We became more lenient on our rules and expectations. We no longer asked her to try harder. She was trying as hard as she could. It was not until we were able to convert our thinking from having to x her that we could relax our expectations and allow her to heal at her own pace. Teresa appeared pleased when she did not vomit after a meal but felt ashamed and horrible if she did. We all tried to take the pressure off and dug deep

into ourselves to nd ways to do this. We needed to behave in a way that was completely different from our usual approach. Teresa appreciated irony, and she and I shared a special moment of connection one day as I left her room saying, Have a great, nauseous day. She replied smiling, Oooh, you get it! After this, she was able to relax and feel less ashamed if she did vomit. We avoided trying to cheer her up, offer any false hope, or diminish any sense of her limitations, as these efforts may have increased feelings of mistrust or helplessness and forced her to unconsciously try harder to prove to us how limited she was. Eventually rules were abandoned because they had the opposite effect. We began building on her successes. The cell phone was now allowed during the day, and she would connect with her mom when her anxiety was high. Teresa was sensitive to her environment and the energy around her. Light and sound could trigger her to not feel well. Although we wanted to take her from her dark, quiet room and bring her into the light of the day room, we resisted because she taught us that her nervous system could not handle that. She could sense when we were tense, which allowed us to be more aware of our own feelings and how they affected others. Whenever possible, we encouraged selfsufciency but only in small steps, so as not to overwhelm her. As time progressed, Teresa went out for walks in her wheelchair, at rst pushed by staff, then propelling it by herself. She also began to wash her own hair as her strength improved. She was supported with goals that would hopefully return her to school and her family. OnGOInG THERaPY Cognitive therapy was ongoing. This treatment is described as effective for somatoform disorders. JPNOnLInE.COM

It focuses on distortions, unrealistic beliefs, and behaviors that are turned into physical symptoms. It has been shown to improve patient functioning and reduce the cost of care (Oyama et al., 2007). Alternative therapies were also introduced into her care. Meditation and prayer became important to Teresa, and she spent time doing both. Biofeedback was added to her care plan. Biofeedback has been around for more than 30 years. It is most useful for stress disorders, especially with a psychosomatic component. It works by recording signals from the body, such as heart rate, temperature, respirations, circulation, and brain waves. (Teresas brain waves were not recorded.) It is used to show the physiological effects of stress and behavior and how they affect the body. The clinician or therapist who teaches the patient must be trained and experienced. The patient must be motivated, and there must be enough sessions for the client to benet (Stens Corporation, 2009). Teresas family worked with the team to arrange for a consulting biofeedback specialist who came in for 1 hour two to three times per week. The therapist brought in a laptop computer program that sent messages back to Teresa in the form of colorful graphs. When Teresa was relaxed, the green-colored graphs were elevated; if she was stressed, the graph would respond to her physical vital signs, and the green graphs would be low. Teresa was taught relaxation techniques, and as she perfected this skill, the biofeedback program would record her success. Another program was a blackand-white, computer-generated picture of a peaceful wildlife scene. As Teresas body relaxed, the picture would come to life in beautiful colors. With the help of these programs, Teresa

KEYPOI N TS
1. Conversion disorder is a psychological disorder in which the essential feature is the presence of symptoms that affect voluntary motor or sensory function. 2. The cause of conversion disorder is not clearly understood, but the term conversion suggests that repressed memories, trauma, or stress may be converted to physical symptoms. 3. This article explores the attitude change in both staff and patient that was needed to achieve the ultimate goal of wellness.
Do you agree with this article? Disagree? Have a comment or questions? Send an e-mail to the Journal, at jpn@slackinc.com. Were waiting to hear from you!

learned about the emotions she always had but had been unable to recognize before, as well as her bodys response to these feelings. These two programs provided two other important elements. Teresa was becoming aware of the connection between her mind and physical body. She was also slowly accepting that there could be a connection between her thoughts and the effects on her body. She was now able to think that perhaps her mind could be responsible for her physical symptoms. We used common examples of emotions causing physical symptoms, such as stress-related hypertension, peptic ulcer disease, or a racing heart rate when speaking in front of an audience, to emphasize that connection. It was helpful for Teresa to have a feeling of control over her body. We monitored her for signs of frustration as she used the equipment without the therapist, allowed time for her to practice, and continued to provide a calm environment. As she experienced success with the programs, her self-esteem began to improve. She became more animated and appeared relaxed and proud of her accomplishments. She assumed the role of teacher and showed the staff how to use the equipment. She now enjoyed seeing her graphs displayed prominently on her wall. Some of the staff took

a turn on the biofeedback equipment and realized it was not as easy as Teresa made it look. We became more mindful of her struggle. We replaced our desire to administer medications with an appreciation for the slow healing Teresa was providing for herself. Because patients with conversion disorder have a tendency to be inuenced by suggestion (Akdemir & Unal, 2006) and because Teresa could now accept that there could be a connection between her mind and body, the treatment team introduced Teresa to hypnosis. According to Stonnington et al. (2006), hypnosis has been used for the treatment of conversion disorder symptoms since Freuds time. Now neuroimaging is reinforcing the idea that conversion symptoms and hypnosis involve similar pathways in the brain. Hypnosis is described as a naturally occurring altered state in which the conscious mind (the reasoning, evaluating, judging part of the mind) is bypassed. With that area suspended and concentration and focus increased, the unconscious mind can reveal hidden feelings while in a total state of relaxation, without fear of criticism. Hypnosis is also described as verbal and nonverbal communication in a state of hyperacuity. It is a focused state in which the sensory 47

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and motor abilities are altered to achieve the appropriate behavior. It could occur during a relaxed state or when the person is walking or doing other motor activity (Kane & Olness, 2004). Two therapeutic uses for hypnosis are to help people control or alleviate some conditions (e.g., smoking) and to gain understanding of the cause of their symptoms. It is during this trance-like state that the patient is very open to suggestions without criticism, which can bring about positive change.

we learned that Teresa having some secrets was a sign of maturity and age-appropriate individuation. She was beginning to have her own thoughts, and we were letting go of our textbook thinking of trauma being the only cause for this kind of illness. Our job was to again provide a safe environment and be there for her if she needed to talk about her feelings that were brought up during hypnosis. Teresas hypnotist, a psychiatrist and licensed hypnotherapist, had been updat-

Communicating in a quiet, calm manner and using imagery...could have a positive effect on the patient.

World with her family, of college, of a job and a car. She spent more time out of her room with other patients, and when they asked what she was in the hospital for she stated, I have conversion disorder. To admit this was another step forward in her recovery. Teresa described to me the time when she felt she became whole again. She said she could feel the moment when her body became reconnected with her soul. For her, there was an actual physical sensation. She said her eyes were now seeing from the normal perspective of her face instead of from above her head. Despite a longer than usual hospitalization fraught with enormous frustration for patient and staff, that day came all too quickly for us. The news spread across three shifts the week before ChristmasTeresa had walked! DISCHaRGE anD lESSOnS lEaRnED On the day of discharge, Teresas wheelchair was packed away, and Teresa walked out of her room smiling, her special pillow and animal replaced by the pocketbook over her shoulder. As she turned and waved to the staff, another patient was coming through the door on a stretcher. Our growth would continue, and there would be a new challenge for us to face. But we had learned valuable lessons from Teresa. The staff began thinking how her treatment could be applied to other patients in our care. Clinical diagnostic questions could be added to the admission process. The team has also considered purchasing biofeedback equipment to add to our sensory stimulation room and to be trained to use it to help specic patients gain control of their anxiety. We came away with the understanding that communicating JPNOnLInE.COM

It is generally used as an adjunct to other kinds of therapy, which was denitely true in Teresas case. Two to three times per week, Teresa traveled with a staff member by taxi to undergo hypnotherapy. Teresa was afraid of it at rst but bragged to her family with pride that the physician had described her as very hypnotizable. She explained that the physician believed her difculty with her body was brought about by an internal conict. This seemed to her to mean that she was very treatable and that at last someone had found a real cause for her symptoms. Many of us were skeptical. Some were sure hypnotherapy would uncover some hideous secret, but we were wrong. Some secrets may have been told only to the hypnotist, but otherwise, Teresa may have felt some anxiety and dislike toward her maturing body and feared facing the future with all of the stress and demands of adult life. As a team, 48

ing Teresas psychiatrist and the team and stated he was pleased with her progress. At one point, he told Teresa she could walk whenever she felt she was ready. The seasons were changing, and as fall turned to winter, we took notice of the slow but incredible ways Teresa was changing as well. Progress notes would detail:
Today patient did not vomit. Patient transferred from bed to wheelchair with one assist. Patient out of room to meet with [hypnotherapist]. No seizure activity noted today.

As talk therapy, biofeedback, meditation, and hypnosis continued, the dark black contact lens was removed, revealing Teresas beautiful blue eyes that now had a new shine to them. Her pale color was replaced with a healthy glow. She was gaining weight as well as a more womanly shape. Teresa began talking of the new chocolate brown boots she wanted for Christmas. She even dared to think of a trip to Disney

in a quiet, calm manner and using imagery to which the patient could relate could have a positive effect on the patient. The staff were now open to many kinds of holistic therapies. We were ready for the opportunity to have another patient show us what work we needed to do together to help them heal themselves. REFEREnCES
Akdemir, D., & Unal, F. (2006). Early onset conversion disorder: A case report. Turkish Journal of Psychiatry, 17, 65-71. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Rev.).Washington, DC: Author. Aybek, S., Kanaan, R.A., & David, A.S. (2008). The neuropsychiatry of conversion disorder. Current Opinion in Psychiatry, 21, 275-280. Bisht, J., Sankhyan, N., Kaushal, R.K., Sharma, R.C., & Grover, N. (2008). Clinical prole of pediatric somatoform disorders. Indian Pediatrics, 45, 111115. Conversion disorder. (2005). Harvard Mental Health Letter, 22(2), 1-3. Conversion disorder. (n.d.). In Encyclopedia

of Mental Disorders. Retrieved May 22, 2009, from http://www.minddisorders. com/Br-Del/Conversion-disorder.html Kane, S., & Olness, K. (Eds.). (2004). The art of therapeutic communication: The collected works of Kay F. Thompson. Carmarthan, Wales, UK: Crown House. Marshall, S.A., Landau, M.E., Carroll, C.G., & Schwieters, B. (2008, December 22). Conversion disorders. Retrieved May 22, 2009, from the eMedicine: Psychiatry Web site: http://emedicine.medscape. com/article/287464-overview Oyama, O., Paltoo, C., & Greengold, J. (2007). Somatoform disorders. American Family Physician, 76(9). Retrieved May 22, 2009, from http://www.aafp. org/afp/20071101/1333.html Powsner, S., & Dufel, S.E. (2009, May 1). Conversion disorder. Retrieved May 22, 2009, from the eMedicine: Emergency Medicine Web site: http://emedicine. medscape.com/article/805361-overview Sar , V . , Aky z, G . , K Kundak i, T . , K Kiziltan , E . , & 4 Dogan4 ,4 O4 . (2004). Childhood trauma, dissociation and psychiatric comorbidity in patients with conversion disorder. American Journal of Psychiatry, 161, 2271-2276. Stens Corporation. (2009). About biofeedback. Retrieved May 22, 2009, from http://www.stens-biofeedback.com/ about_biofeedback.html

Stonnington, C.M., Barry, J.J., & Fisher, R.S. (2006). Conversion disorder. American Journal of Psychiatry, 163, 1510-1517.

Ms. Tocchio is a staff nurse, McLean Hospital SouthEast, Brockton, Massachusetts. The author discloses that she has no signicant nancial interests in any product or class of products discussed directly or indirectly in this activity, including research support. The author thanks Joan Kovach, APRN, BC, Nurse Manager, for her support and encouragement in writing this article. She also thanks all of the team members who helped with this patients recovery. The author also acknowledges the leadership of Jeffrey D. Rediger, MD, MDiv, Medical Director, for his vision and willingness to seek the best treatments for his patients and his concern and encouragement of his staff. Teresa has given her permission for her story to be told. Address correspondence to Sandra L. Tocchio, RN, 46 Pine Street, Hanover, MA 02339-1534; e-mail: santoch@ aol.com. doi:10.3928/02793695-20090706-02

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