This in the past accounted for 1 to 2 percent of admissions to a neurologic service and a greater number of outpatient visits but now is represented mainly by hysterical seizures and convulsions, “psychogenic nonepileptic seizures”, or PNES (see further on and Chap. 15). The more general chronic form that does not include epileptic-like attacks usually has its onset in the teens or early twenties, almost exclusively in young women; a very few cases begin before puberty. Once established, the symptoms recur intermittently, although with reduced frequency, throughout the adult years even to an advanced age. No doubt there are cases of lesser severity in which symptoms occur only a few times or perhaps only once, just as there are mild forms of other diseases. The patient may be seen for the first time during middle life or later, and the earlier history may not at first be forthcoming. Careful probing almost invariably reveals that the earliest manifestations of the chronic form of illness had appeared before the age of about 25 years.
Other important data are also revealed by eliciting a careful past history. During late childhood and adolescence, the normal activities of the patient, including education, had often been interrupted by periods of ill-defined illness. In the past, rheumatic fever, and in the current era, chronic fatigue, Lyme disease, sick building syndrome, or multiple environmental allergy may be carried as explanatory diagnoses from other physicians or the patient’s research on the Internet. Later in life, problems in work adjustment and marriage are frequent. Notable in many cases is a high incidence of marital incompatibility, separation, and divorce. The patient’s life history is punctuated by symptoms that do not conform to recognizable patterns of medical and surgical disease. For these ailments, many forms of therapy including surgical operations may have been performed.
In the past, rarely had adult life been reached without at least one abdominal operation for vague abdominal pain, persistent nausea and vomiting, or an obscure gynecologic complaint. Often the indications for the surgical procedures were unclear; moreover, the same symptoms or others often recurred to complicate the convalescence. The biographies of these patients are replete with disorders that center about menstrual, sexual, and procreative functions. Menstrual periods may be painfully prostrating, irregular, or excessive. Sexual intercourse may be painful or unpleasant. Pregnancies may be exceedingly difficult; the common vomiting of the first trimester may persist all through the gestational period, with weight loss and prostration; labor may be unusually difficult and prolonged, and all manner of unpredictable complications are said to have occurred during and after parturition.
Hysteria in its fullest form is a polysymptomatic disorder, implicating at some time and in some patients, almost every organ system. In a study of 50 unmistakable cases of hysteria (as compared with a control group of 50 healthy women), the most frequent symptoms reported by Purtell and colleagues were headache, blurred vision, lump in the throat, loss of voice, dyspnea, palpitation, anxiety attacks, anorexia, nausea and vomiting, abdominal pain, unusual food allergies, severe menstrual pain, urinary retention, painful intercourse, paresthesias, dizzy spells, nervousness, and easy crying.