Several approaches to discussing the symptomatology with the patient have been suggested. At one extreme is a confrontative approach in which the patient is told the symptoms are psychologic, or “in your head.” We have found this to be counterproductive and almost always provokes an angry response that does not aid clinical improvement. At the other extreme is complete avoidance on the part of the physician, an approach that is almost as unproductive. We prefer to ask the patient if the symptoms can in some way be the result of “stress” or an upsetting recent experience. On occasion, in private, we will inquire about childhood sexual abuse and often get an affirmative response from the patient, with later confirmation by a spouse or sibling. Very powerful is nonjudgmental but firm reassurance that there is no serious disease. We have found it useful to list the diseases that have been excluded by examination and testing: brain tumor, stroke, amyotrophic lateral sclerosis, multiple sclerosis, etc. This often evokes an acknowledgment by the patient that one of the diseases had been a preoccupying concern. We then indicate, without using psychologic terms, that the brain may at times adopt certain patterns of behavior that do not reflect structural damage, and, furthermore, that these patterns can be unlearned with physical therapy and time, as described in the following text.
That the patient’s response to these conversations varies widely is not surprising. One group seems not to mind and to be relieved by the expression of concern and reassurance that there is no dangerous disease at the root of the problem. They can be sent to a physical therapist and may do well in the short run. Another group is indignant and unlikely to consult the physician again; several in the past have refused to pay the doctor’s bill. Some have objected to the explanation based on their own view, often derived from research on the Internet and with similarly afflicted persons, that Lyme disease, chronic viral infection, environmental toxins, allergies, etc., are to blame. A few of these cases have the flavor of a delusion. All that the physician can offer here is an openness to see and reexamine the patient in several months; “cure” has no meaning in these instances and there is a high likelihood that such individuals will see a long line of doctors.
Some of our better results have been obtained by indicating that the neurologic symptoms are a “pattern of brain circuits” or “constitutional” weakness that can be overcome by physical and other therapies. Once the current neurologic disorder has disappeared, it may be helpful to counsel the patient in ways to prevent its recurrence. Family members can be given the same explanation. A regimen of physical therapy should be instituted, using an experienced therapist and setting simple goals for success. Every subsequent illness in such patients should be evaluated objectively, so as not to overlook any medical or surgical disease, which may strike a hysterical patient just as it does any other person.
The success of any of these programs over a long period is unknown. The eradication of recently acquired hysterical symptom is relatively easy. The real test is whether it enables the patient to adjust satisfactorily to family and society and to perform daily activities effectively, and whether it prevents addiction, unnecessary medical treatments, and operations. Estimates of the recurrence rate of hysterical symptoms vary widely from 12 to 80 percent. In the series reported by Gatfield and Guze and by Merskey, the recurrence of somatic symptoms of similar or of other types was as high as in sociopathies. We have seen a few patients with monosymptomatic hysteria (paraparesis, bizarre gait, crippling dystonia) that persisted for years on end regardless of treatment. The use of a wheelchair for more than several days has been a bad prognostic sign in these cases.