Hysterical trances or fugues, in which the patient wanders about for hours or days and carries out complex acts may simulate temporal lobe epilepsy or any of the conditions that lead to confusional psychosis. The most reliable point of differentiation comes from observation of the patient, who, if hysterical, is likely to indicate a degree of alertness and promptness of response not seen in temporal lobe seizures or confusional states. Following the episode, an interview with the patient—under the influence of hypnosis, strong suggestion, or midazolam (formerly used was amobarbital [Amytal])—will often reveal memories of what happened during the episode. This helps to exclude the possibility of an epileptic spell.
Hysterical Paralyses, Gait, Sensory Loss, and Tremors (See Also Chaps. 3, 4, and 6)
Hysterical palsies may involve an arm, a leg, one side of the body, or both legs. If the affected limb can be moved at all, muscle action is weak and tremulous. Movements are slow, tentative, and poorly sustained; often it can be demonstrated that the strength of voluntary movement is proportional to the resistance offered by the examiner, thus imparting a “give-way” character, as noted in the discussion of these signs in Chap. 3. One can detect by palpation that agonist and antagonist muscles are contracting simultaneously, thereby holding the limb in place rather than opposing the examiner, and when the resistance is suddenly withdrawn, there is no follow-through or rebound, as is normally the case. Many other signs have been devised to demonstrate inconsistencies with normal physiologic principles and a purposive lack of cooperation. These are elaborated upon in the articles by Stone and associates (2002b and 2013a, b). The discrepancies are usually found by testing an agonist, antagonist, or fixator movement while the patient is focused on making an effort with another group of muscles (e.g., the Hoover sign; see Chap 3). Muscular tone in the affected limbs is usually normal but slight resistance may sometimes be found. A seeming lack of effort and the absence of full compliance with the examiner’s requests during the testing of muscle strength, while common in hysterical patients, are not confined to them; one encounters such findings not infrequently during the examination of suggestible but nonhysterical patients who harbor a neurologic disease and in those with a painful condition in an adjacent joint.
Walking and standing may be impossible (astasia-abasia) or the gait may be bizarre with collapsing legs that bring the patient to a squat, or a “skating” gait in which 1 foot is pushed ahead of the body. Other forms—some quite absurd, as noted in Chap. 6—are easily recognized as inconsistent with the makings of the nervous system in disease. Weakness and poor balance are combined elements in both the quadriparetic and hemiparetic forms. In Keane’s informative series of 60 cases of hysterical gait, the hemiparetic and monocrural forms were twice as frequent as the quadriparetic. The gait disorder is sometimes difficult to describe because of its variability. Sudden falls without voluntary protective movements and inconsistencies of balance are helpful features. Difficulty in walking and moving the legs that disappears when the patient is seated is, of course, not unique to hysteria; it also occurs in so-called frontal lobe gait apraxia and in ataxia from midline cerebellar lesions and in hydrocephalus.
In a most remarkable and recalcitrant form of psychogenic movement disorder, maintenance of the limbs in a rigid or dystonic posture for a long time may result in a bed-bound, crippled state with severe flexion pseudocontractures of the limbs. We have seen 1 such case of 18 years’ duration. The tendon reflexes are usually normal if they can be tested, but with hysterical rigidity and muscular contractures, the abdominal and plantar reflexes may be suppressed.