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Special Neurologic Syndromes of Hysterical Origin
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A few hysterical syndromes occur with regularity and every physician may expect to encounter them Most are neurologic in nature They constitute some of the most puzzling diagnostic problems in medicine Hysterical Pain This may involve any part of the body; generalized or localized headache, atypical facial pain, vague abdominal pain, and chronic back pain with camptocormia are the most frequent and troublesome In many of these patients the response to analgesic drugs has been unusual or excessive, and some of them are addicted The hysterical patient may respond readily to a placebo as though it were a potent drug, but it should be pointed out that this is a notoriously unreliable means of distinguishing hysterical pain from that of other diseases A greater error is to mistake the pain of osteomyelitis or visceral tumor before other symptoms have developed for a manifestation of hysteria There are several helpful diagnostic features of hysterical pain: (1) the patient s inability to give a clear, concise description of the type of pain; (2) the location of the pain does not conform to the pattern of pain in the familiar medical syndromes; (3) the dramatic elaborations of its intensity (speaking in in ated metaphors like a giant knife stabbing ) and its effects on the body ( tearing my limb off ); (4) its persistence, either continuous or intermittent, for long periods of time; (5) the assumption of bizarre attitudes and postures; and, most important; (6) the coexistence of other clinical features or previous attacks of hysterical nature Hysterical Vomiting This is often combined with pain and tenderness in the lower abdomen and results in unnecessary appendectomies and removal of pelvic organs in adolescent girls and young women The vomiting often occurs after a meal, leaving the patient hungry and ready to eat again; it may be induced by unpleasant circumstances Some of these patients can vomit at will, regurgitating food from the stomach like a ruminant animal Vomiting may persist for weeks with no cause being found Weight loss may occur, but seldom to the degree anticipated As remarked earlier, the usual rst-trimester vomiting of pregnancy may continue
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THE NEUROSES AND PERSONALITY DISORDERS
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the gait may be bizarre with collapsing legs that bring the patient to a squat, or there is a skating gait in which one foot is pushed ahead of the body, and other forms that are easily recognized as inconsistent with the makings of the nervous system in disease (page 107) 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 dif cult to describe because of its variability Sudden falls without voluntary protective movements and inconsistencies of balance are helpful features Other features are discussed in Chap 7 on gait disorders Dif culty in walking and moving the legs while 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 the most remarkable and recalcitrant cases, maintenance of the limbs in a rigid or dystonic posture for a long time may result in a bed-bound, crippled state with severe exion pseudocontractures of the limbs We have seen one such case of 18 years duration The tendon re exes are usually normal if they can be tested, but with hysterical rigidity and contractures, the abdominal and plantar re exes may be suppressed Anesthesia or hypesthesia is almost always inadvertently suggested by the physician s examination Seldom is sensory loss a spontaneous complaint, although numbness and paresthesias are not uncommon in hysterics The sensory loss may involve one or more limbs below a sharp line (stocking and glove distribution), or may involve precisely one half of the body, or vibratory sense may be lost over precisely one half of the skull (a test favored to demonstrate hysterical hemianesthesia) Touch, pain, taste, smell, vision, and hearing may all be affected on that side, which is an anatomic impossibility from a single lesion Other aspects are discussed in Chap 9 The sometimes-stated notion that hysterical paralysis and sensory de cits are more common on the left side is probably untrue according to Stone and colleagues The features of hysterical tremor have been described on page 84 To be emphasized are the cessation of tremor with distracting tasks eg, complex nger movement patterns on the side opposite the tremor (such as touching the fourth, second, and fth ngers in sequence rapidly), or re xation of the eyes on a target, or walking on the outside of the heels The ability of the examiner to chase the tremor to proximal or distal parts of the limb by holding and immobilizing other parts is highly characteristic Also a fairly dependable sign is worsening of a tremor with loading, that is accomplished by placing a heavy object in the patient s hand (most basal ganglionic and cerebellar tremors are muted by this maneuver) Hysterical Blindness (See page 219) This dramatic event may affect one eye or both and may be coupled with hemiparesis or appear in isolation The symptoms usually develop suddenly, often after an altercation or other emotionally charged event The patient stares straight ahead blandly when undisturbed but may squint or move the head as if straining to see when asked to view an object Some such individuals can reduce re exive blinking in response to a visual threat The psychic nature of the problem may be recognized by a nurse who observes the patient reaching for a cup or for the phone The preservation of vision is con rmed by the presence of normal pupillary re exes and of optokinetic nystagmus, although one occasionally encounters a patient who has learned to suppress the latter response as well A mirror passed slowly in the
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patient s central vision often engages eye movements Other similar maneuvers are favored by different examiners The presence of visual evoked responses also con rms the intactness of retino-occipital connections The patient expresses little concern about her condition, which is usually short-lived Cortical blindness and variants of the Balint syndrome (pages 404 and 406) from bioccipital infarcts are the main diagnostic considerations Convergence spasm, occurring as an isolated phenomenon, is practically always of hysterical nature (page 226) A related phenomenon involves the self-administration of mydriatic eyedrops by health care personnel The patient arrives on the emergency ward complaining of reduced vision (expected) or with headache and claiming to have an intracranial mass This behavior is perhaps more sociopathic (or malingering) than hysterical Hysterical Amnesia 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 an insane 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 ve for two plus two)
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Hysteria in Men (Compensation Neurosis in Men and Women)
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As stated earlier, symptoms of the same nature as those in hysteria do occur in men, most often in those trying to avoid legal dif culties or military service or attempting to obtain disability or pension payments, or, compensation following injury Sociopaths may also present with this type of illness Unless such a motivating factor can be identi ed, 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 (eg, seizures ) and the symptoms, particularly chronic pain, may be con ned 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 rst 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 have been previously suspected of malingering
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