Whether conversion symptoms are consciously produced by the patient or arise unconsciously, without the patient’s awareness, is a question that has been debated endlessly without resolution. Babinski attributed the symptoms to hypersuggestibility. In fact, he defined hysteria as an illness whose symptoms could be induced (and removed) by suggestion. There is strong evidence to support this idea, as most patients can be readily hypnotized and their symptoms temporarily eliminated by this procedure or by an interview and examination under the influence of midazolam. The present authors place great credence on this notion of hypersuggestibility, in keeping with older studies that emphasized these patients’ unusual susceptibility to hypnosis and suggestion. Fascinating in this regard were the observations of Charcot’s students that on their wards, the patients’ symptoms disappeared when he died.
Some insights can be obtained from studies of functional imaging in hysterical paralysis (see also Chap. 3). In general, the contralateral prefrontal cortex is suppressed when the patient with hysteria attempts to move a limb, suggesting to Spence and colleagues a “choice” of an active attempt not to move the limb. The pattern of activation was quite different from volunteers who purposefully feigned paralysis and who did not demonstrate such reduced prefrontal activity. When the hysteric with unilateral sensory loss is stimulated on the affected limb, there is no activation of the contralateral sensory cortex but bilateral stimulation results in activation of the appropriate regions in both hemispheres (Ghaffar et al). Some of the recent findings using functional imaging in hysterical states are reviewed by Carson and colleagues.
As pointed out by Carothers and by Guze and colleagues, hysteria and sociopathy may be closely related. Hysteria is a disease of women and sociopathy mainly of men. As restated by Cloninger and colleagues (1975), they may constitute expressions of a single underlying variable. This relationship is also supported by family studies. First-degree male relatives of hysterical women have an increased incidence of sociopathy and alcoholism; among first-degree female relatives of convicted male felons, there is an increased prevalence of hysteria. Moreover, careful histories of sociopathic girls reveal that many of them develop the full syndrome of hysteria. Women felons often present a mixed picture of hysteria and sociopathy, according to Cloninger and Guze.
The characteristic age of onset; the longitudinal history of recurrent multiple complaints as outlined earlier; the attitude of the patient and the manner of presenting her symptoms; the incongruity of affect and clinical state; the discrepancy between the neurologic deficit and the signs on examination; the impossibility of explaining the patient’s signs on an anatomic or physiologic basis; and the absence of symptoms and signs of other medical and surgical disease will permit an accurate diagnosis in the majority of cases. Certain tests designed to reveal normal functioning of a limb, of vision, and of gait already have been mentioned. Stone and colleagues (2009) assessed over 1000 patients who were given the diagnosis of a functional disorder and reported that only 0.4 percent were later found to have an organic explanation for their symptoms.
There is a significant overlap of hysteria and other medical and neurologic diseases. On record are numerous studies in which patients with an initial diagnosis of hysteria by general physicians were followed for many years. Up to one-third of them (far less in most series) turned out eventually to have an “organic condition” that, in retrospect, explained the initial symptoms (Couprie et al). This emphasizes that the original clinical diagnosis of hysteria is sometimes erroneous, although numerous other surveys emphasize the opposite, as noted below. When the diagnostic criteria in these cases are closely analyzed, it becomes apparent that the diagnosis was made solely by the “discrepancy method”—that is, the patient’s symptoms or signs were not deemed to be credible manifestations of disease, based mainly on the clinical experience of the examiner. Of course, this assumes that the examiner has a wide experience; unfortunately for the novice, many syndromes are unknown or incomprehensible.