Patients brought to a hospital in a state of amnesia, not knowing their own identity, are usually hysterical females or sociopathic males involved in a crime. Usually, after a few hours or days, with encouragement, they divulge their life history. Epileptic patients or victims of a concussion, transient global amnesia, or acute confusional psychosis do not come to a hospital asking for help in establishing their identity. Moreover, the complete loss of memory for all previous life experiences by patients who are otherwise able to comport themselves normally is not observed in any other condition.
In the Ganser syndrome (amnesia, disturbance of consciousness, and hallucinations) patients pretend to have lost their memory or to have become insane. They may act in an absurd manner, simulating the way they believe that a deranged or demented person would act, and give senseless or only approximate answers to every question asked of them (calling the color red blue or answering 5 for 2 + 2).
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As stated earlier, symptoms of the same nature as those in hysteria occur in men, most often in those trying to avoid legal difficulties or military service or attempting to obtain disability or compensation following injury. Sociopaths often present with this type of illness. Unless such a motivating factor can be identified, the diagnosis of hysteria in the male should be made with caution. In compensation neurosis, as in the classic form of hysteria, multiple symptoms are reported; many of the symptoms are the same as those listed under female hysteria. Or the patient may be monosymptomatic (e.g., “seizures”) and the symptoms, particularly chronic pain, may be confined to the neck, head, arm, or low back. The description of symptoms tends to be lengthy and circumstantial, and the patient fails to give details that are necessary for diagnosis. A tangible gain from the illness may be discovered by simple questioning. This is usually in the form of monetary compensation, which, surprisingly, is sometimes less than that which the patient could earn if he returned to work. Most such patients are actively engaged in litigation when first seen. Another interesting feature is the frequency with which the patient expresses extreme dissatisfaction with the medical care given him; he is often hostile toward the physicians and nurses. Many of these patients have already been subjected to an excessive number of hospitalizations and rather dramatic mishaps have allegedly occurred in carrying out diagnostic and therapeutic procedures. The majority of these patients were previously suspected of malingering.
Curiously, women who suffer injury at work or are involved in auto accidents may exhibit the same symptoms and signs of compensation neurosis as men, but in our experience, do so infrequently or at least less overtly.
Psychoanalytic theory, which held that both conversion and dissociative symptoms were based on particular psychodynamic mechanisms, is impossible to affirm or refute. Although subject to some question of fabricated recall, we have been impressed at the high rate of childhood sexual abuse reported by women with severe monosymptomatic cases of hysteria or fugue states. This conforms to some extent with psychoanalytic views. An acknowledged history of childhood abuse related by the patient alerts the physician to the possibility of hysteria. Sociologic and educational factors may be important, for it has been observed that hysterical women as a group tend to be less intelligent and less educated than nonhysterical women but there are many exceptions. A genetic causation must also be considered since family studies have disclosed that approximately 20 percent of first-degree relatives of female hysterics have the same illness, an incidence 10 times that in the general population. This supports, in some views, the idea that hysteria is a disease and not merely a surfacing of a basic personality disorder (see Goodwin and Guze).
Pathophysiology of Hysteria