This may involve any part of the body; generalized or localized headache, “atypical facial pain,” vague abdominal pain, and chronic back pain with camptocormia are the most frequent and troublesome. In many of these patients the response to analgesic drugs has been unusual or excessive, and some of them are addicted. The hysterical patient may respond readily to a placebo as though it were a potent drug, but it should be pointed out that this is a notoriously unreliable means of distinguishing hysterical pain from that of other diseases. A greater error is to mistake the pain of osteomyelitis or visceral tumor—before other symptoms have developed—for a manifestation of hysteria. There are several helpful diagnostic features of hysterical pain: (1) the patient’s inability to give a clear, concise description of the type of pain; (2) the location of the pain does not conform to the pattern of pain in the familiar medical syndromes; (3) the dramatic elaborations of its intensity (speaking in inflated metaphors—“like a giant knife stabbing”) and its effects on the body (“tearing my limb off”); (4) its persistence, either continuous or intermittent, for long periods of time; (5) the assumption of bizarre postures; and, most important; and (6) the coexistence of other clinical features or previous attacks of hysterical nature.
This is often combined with pain and tenderness in the lower abdomen and had many times in the past resulted in unnecessary appendectomies and removal of pelvic organs in adolescent girls and young women. The vomiting often occurs after a meal, leaving the patient hungry and ready to eat again; it may be induced by unpleasant circumstances. Some of these patients can vomit at will, regurgitating food from the stomach like a ruminant animal. Vomiting may persist for weeks with no cause being found. Weight loss may occur, but seldom to the degree anticipated. As remarked earlier, the usual first-trimester vomiting of pregnancy may continue throughout the entire 9 months, and occasionally pregnancy will be interrupted because of it. Anorexia may be a prominent associated symptom and must be differentiated from anorexia nervosa–bulimia, another closely related disease of young women. Factitious elf-induced vomiting is more aligned with malingering, with which hysteria may be allied.
Psychogenic Seizures (PNES), Trances, and Fugues (See Also Chap. 15)
These conditions seem to be no less frequent than in the days of Charcot, when la grande attaque d’hysterie was often exhibited before medical audiences, but it is quite familiar to all neurologists and one of the main concerns of epileptologists. To witness an attack is of great assistance in diagnosis but electroencephalogram (EEG) monitoring is often required for certainty. The lack of an aura, initiating cry, hurtful fall, or incontinence; the presence of peculiar movements such as grimacing, squirming, thrashing and flailing of the limbs, side-to-side motions of the head, and striking at or resisting those who offer assistance; the retention of consciousness during a motor seizure that involves both sides of the body; a long duration of the seizure, its abrupt termination by strong sensory stimulation, lack of postictal confusion, and failure to produce a rise in creatine kinase—are all typical of the psychogenic attack. Sometimes hyperventilation will initiate an attack and is therefore a useful diagnostic maneuver. Both epilepsy, particularly of frontal-lobe type, and hysteria may occur in the same patient, a combination that invariably causes difficulty in diagnosis as discussed in Chap. 15.