The mental examination of the patient with hysteria demonstrates a lack of precision in relating the details of the illness. Questions regarding the chief complaint usually elicit a narration of a series of incidents or problems, many of which prove to have little or no relevance to the question. Memory defects (amnesic gaps) are apparent while the history is being taken; the patient appears to have forgotten important segments of the history, some of which he had clearly described in the past and are part of the medical record. The description of symptoms is dramatic and not in accord with the facts as elicited from other members of the family. Often, a rather casual demeanor is manifest, the patient insisting that everything in her life is quite normal and controlled, when, in fact, her medical record is checkered with instances of dramatic and unexplained illness. This calm attitude toward a turbulent illness and seemingly disabling physical signs is so common that it has been singled out as an important characteristic of hysteria, la belle indifference. Other patients, however, are obviously tense and anxious and report frank anxiety attacks. Emotional reactions are superficial and scenes that are disturbing to others are quickly forgotten. Claims of early life sexual or physical abuse are common and often prove to be true, or sometimes are not valid; when present, they probably play a role in the genesis of some cases (see further on).
There are no pathognomonic findings. Although many in the past have commented on the rather youthful, girlish appearance and coquettish (“seductive”) manner of the patients, these by no means characterize most patients in the current era. The abdomen may be diffusely and exceedingly tender but without other signs of abdominal disease. The so-called stigmata of hysteria—that is, corneal anesthesia; absence of gag reflex; spots of pain and tenderness over the scalp, sternum, breasts, lower ribs, and ovaries—are often suggested by the examiner and are too inconsistent to be of much help in diagnosis. The relative value of various features of the history, examination and psychological profile that may be of value in diagnosis were summarized by Lazare, and the psychiatric features were summarized by Raskin et al (in now outdated terms) but the point being that few are definitive. The variation and pleomorphism of the physical signs are limited only by the patient’s ability to produce them by voluntary effort. Accordingly, symptoms and signs that are beyond volitional control should not be accepted as manifestations of hysteria. Sometimes the patient’s physical signs are an imitation of those of another member of the family (“folie à deux”) or are evoked by a stressful event in the patient’s personal life. However, this may not be disclosed at the time of the first examination.
Special Neurologic Syndromes of Psychogenic Origin
A few hysterical syndromes occur with regularity that every physician may expect to encounter them. Most are neurologic in nature. They constitute some of the most puzzling diagnostic problems in medicine.