Distinguishing Hysteria From Neurologic Disease

Presented By:Joseph S. Ferezy, D.C.

Hysteria Is a Mental Illness Which Alters Sensory or Motor Function but Without a Lesion in the Parts of the Nervous System That Anatomically and Physiologically Should Mediate the Symptoms.

Hysteria May Closely Mimic Organic Disorders of Mentation, Sensation, and Motor Function.

The Hysterical Patient Has a Functional Rather Than an Organic Disorder. In Mild Cases, or in Cases Involving Only a Pain Complaint the Differentiation Can Be Quite Difficult. However, in Full-blown Cases, Certain Principles Make the Diagnosis Relatively Easy.

Distinction Between Hysteria and Malingering

Psychiatrists Assume That Hysterical Symptoms Represent Unconscious Mental Mechanism for Relief of Anxiety Primary Gain Consists of the Relief of Anxiety

Secondary Gains Consist of Relief From Duties and Responsibilities and the Achievement of Manipulative Control Over the Emotional Responses of Others

The Origins of the Symptom and the Purposes It Serves Are Presumed to Remain at a Subconscious Level in Hysteria.

The Malingerer Is Presumed to Be Purposefully and Consciously Faking Disease to Achieve Some Immediate GoalMonetary Compensation in a Lawsuit

To Appear Mentally Ill in a Criminal Action

Either Patient, Hysteric or Malingerer, Has a Serious Mental Problem. Do Not Try to Enter the Patient's Mind to Decide Just How Conscious or Unconscious the Symptom Is. That Is Not the Physician's Task.

Criteria for the Diagnosis of Hysteria

Explicit Criteria Presence of Symptoms That Do Not Match Organic Patterns

The Symptoms Reflect the Patient's Notions of Body

Absence of Signs of Organic IllnessSymptoms Are Maximal but Signs Are AbsentHistory of Psychiatric Illness or StressesFull Remission of the Symptom With Time

Historical Criteria

Pseudoneurological Symptoms of Hysteria Usually Manifest in Patients 10 to 30 Years

Long History of a Disordered Personality

Some Immediate Emotional Stress Precedes and Precipitates the Hysterical Symptom.

The History of Longstanding Emotional Problems and the Precipitating Event Is Essential to the Diagnosis of Hysteria. Don't Diagnose Hysteria in a Previously Well Adjusted 60-year-old Patient With the Sudden Onset of Neurologic Symptoms That Could Be Organic.

Mental Status Criteria

Appears Blandly Indifferent (La Belie Indifference)

Rarely Seems Concerned or Asks About the Cause or Prognosis

Organic Paraplegic

Bland Indifference

Since the Symptom Serves As a Defense Against Overt Anxiety, the Patient Feels More Comfortable With the Symptom Than the Anxiety That It Masks.

With Some Hysterical Symptoms, Particularly Sensory Ones Such As Pain, the Patient Overreacts With Much Wailing or Dramatic Prostration. The Art of Diagnosis Is to Recognize the Disproportionate Reaction in Either Case.

The Hysterical Patient

While Focusing on the Disability It Gets Worse

Also Gets Worse in the Presence of Family Members or Acquaintances.

May HyperventilateBetter When DistractedStress Looks Similar in Organic Disease

Monocular Diplopia

Does Not Follow Any of the Laws of Diplopia

Shows No Ocular MalalignmentsTrue, Organic Monocular Diplopia Can Occur From Dislocated Lens, Retinal Fold, Detachment, Elevation, or Iris Hole, but the Exam and Ophthalmoscopy Differentiate Easily.

Hysterical Disorders of Vision

Visual Field DefectsMonocular DiplopiaDiminished Vision or Blindness

Hysterical Visual FieldsTypically Concentric Constriction, Tunnel or Tubular Vision In Tunnel Vision Visual Field Remains the Same Size at Various Visual Target Distances. (Normally Field Expands With Increasing Distance.

Closely Allied Is the Spiral Visual Field, Size of the Field Diminishes on Successive Trials

Hysterical Blindness

Eyes Often Show Fixation Upon and Attraction to Moving Objects

Patient Retains Pupillary Light Reactions

Fundus Appears NormalMost Patients Will Show Optokinetic Nystagmus (Railroad Nystagmus)

Vep’s Are Normal

Monocular Hysterical BlindnessPatient May Be Induced to See Double by Prisms or Canthal Compression, Proving That the Blind Eye Has Vision

**Acute Retrobulbar Neuritis Can Cause Complete Blindness in One Eye and a Normal Appearing Fundus

**In Anton's Syndrome, a Bilateral or Unilateral, Occipital Lobe Lesion Causes Bilateral Cortical Blindness, Yet the Pupillary Responses Remain Intact.

Hysterical Deafness

May Show a Startle Response Electroencephalogram Done During Sleep Will Show an Alerting Response to Sound, Establishing the Integrity of the Auditory Pathway. Audiologists Have Several Methods of Manipulating Sound to Recognize Hysterical Loss of Hearing

Baer’s Are Normal **Some Patients With Acute Viral Illness Suddenly Lose Hearing Even Though They May Show No Other Evidence of Neurologic Disease

Hysterical Somatosensory Disorders

Usually Complain of Anesthesia

All Sensory ModalitiesOnly One Modality = Touch or PainVirtually Never Complain Solely of Loss of Vibration or Position Sense

Paresthesia Hyperesthesia

The Nonanatomical Distributional Pattern of the Sensory Loss Gives the Best Immediate Clue to Hysteria. Hysterical Sensory Losses Conforms to the Patient's Mental Image of the Body, Not the Actual Anatomic Pattern of Innervation by Peripheral Nerves, Nerve Roots, or Central Pathways.

In Hysterical Hemianesthesia. The Patient Not Only Loses All Somatic Sensation From One-half of the Body but Also May Lose Sight, Hearing, Taste, and Smell on the Affected Side, an Obvious Anatomic Impossibility.

The Border Between the Anesthetic and Normal Zone, Although Usually Sharp, May Change From Time to Time.

Vibration Travels Some Distance Through the Bone. The Intact Side Registers the Vibration Even With the Fork Some Little Distance Away From the Midline.

Some Inversions of the Body Parts Can Provide a Quick Answer to Hysterical Hemisensory Loss; The Hysterical Patient May Move the Inverted Finger

Sensory Screen

With Anesthesia for All Modalities, Without Paralysis, You Must Find Associated Areflexia, Hypotonia, and Sensory Dystaxia

Sensory “Fake Outs”

Elicit a Rhythm of AnsweringLook for Exactly Opposite Answers With 100% Accuracy

Hysterics Respond Very Slowly and Deliberately to Sensory Stimuli During the Examination (Under-reaction)

Others Manifestly Overreact to Sensory Stimuli

Sensory Caveats

Organic Pain May Be Referred to or Radiate Beyond the Confines of an Anatomic Territory

On Some Occasions Patients With Thalamic or Parietal Lesions Will Show Hemisensory Losses That Suggest Hysteria

The Patient May Have an Organic Process With a Functional Overlay

Sensory Caveats

Some Patients With Organic Disease Have True Hyperesthesia (Causalgia)

Trigger Zones (Trigeminal Neuralgia)

Hysterical Disorders of Motor FunctionParalysis

May Affect Cranial Nerve Muscles Causing Aphonia or Dysphagia

Globus Hystericus Monoplegia Hemiplegia Paraplegia

Hyperkinesias Tremors Spasms

Hysterical Tremor

Perhaps the Commonest Form of Psychogenic or Functional Paralysis, Impotence, Generally Is Not Regarded As a Form of Hysteria Because It Represents Failure of Automatic Rather Than Willfully Directed Muscular Activity.

Oculomotor Manifestations of Hysteria

TicsBlepharospasm

Eyelids Remain Tonically ClosedConvergence Spasm

Pupils Constrict Along With the Forceful Adduction of the Eyes

Pseudo Vith-nerve Palsy Abducting Eye Deviates Inward

Hysterical Aphonia-dysphagia

May Become Completely SpeechlessNormal Vocal Cord Action During Laryngoscopy

Strong Cough Proves Vocal Cords Can, in Fact, Act Forcefully

No Palatal PalsyNo Difficulty Breathing or Swallowing

Hysterical Aphonia-dysphagia

Whispers With Perfect Articulation

The Patient May Talk or Phonate During Sleep

Hysterical Disturbances of Station and Gait

Inability to Stand (Astasia) or Inability to Walk (Abasia), or Both (Astasia-abasia)

Typically Shows Wild Gyrations When, but Rarely Falls, or Falls Into the Examiner's Arms or a Chair, Without Suffering Bodily Injury

Hysterical Disturbances of Station and Gait

The Wildness of the Gyrations Without Falling Leaves No Doubt That the Patient Has Competent Balance

In Bed, or Sitting, the Patient May Show No Disability or Only Minor Disturbances of Movement

Hysterical Disturbances of Station and Gait

In Doing the Romberg Swaying Test, the Patient With Astasia-abasia May Show a Great Increase in Swaying Upon Eyelid Closure Distract Patient by Count Slowly to 25

Ask Patient to Close the Eyes Observe Normal Upright Posture

Hysterical Paresis or Paralysis of Trunk and LimbsThe Patient's Demeanor During Testing Often Provides a Clue

Usually the Patient Makes a Great Show of Effort to Move the Afflicted Part

The Hysteric With an Incompletely Paralyzed Part Usually Moves It Very Slowly and Oscillates the Part.

Hysterical Ataxia

Hysterical Paresis or Paralysis of Trunk and Limbs

The Patient Will Move the Part During Sleep

The Patient Will Move the Part When Dressing

Functional Wrist Drop, Watch for Action of the Wrist Extensors When You Ask the Patient to Grip Your FingersStrongly

Hysterics Rarely Show Paralysis in Individual Muscles or Groups of Muscles Innervated by a Single Peripheral Nerve or Root, nor Do Their Limbs Assume Organic Postures. Of Course, the Muscle Stretch Reflexes and Plantar Responses Remain Normal.

The Hysterical Patient With Paraplegia, Rarely Loses Bladder and Bowel Control.

Hysterical Seizures, Syncope, and Loss of ConsciousnessFrequently Have Various Types of Dizziness, Blackout Spells, Fainting, or Pseudoepileptic Seizures

Often Occur in Association With Hyperventilation

Have the Patient Hyperventilate for 3 Min to See Whether It Reproduces the Episodes

Lapses of Consciousness Occur After Some Identifiable Precipitating Event. Most Commonly They Occur in the Presence of Someone Emotionally Significant to the Patient, Such As Parent or Lover, or to Avoid Some Unpleasant Circumstance

Usually Hysterical Patients Do Not Injure Themselves If They Fall, nor Do They Bite Their Tongue, or Become Incontinent, All of Which Frequently Occur With Organic Syncope or Epileptic Seizures

If You Can Observe an Episode, You Generally Will Find That the Patient Does Not Show the Autonomic Phenomena of Organic Syncope or Seizures, With Distinct Changes in Blood Pressure, Pulse Rate, or Pupillary Size.

Eeg and Ekg Monitoring May Exclude Epilepsy or Organic Syncope by Showing Normal Records During an Hysterical Attack. Always Draw a Sample of Blood to Measure Glucose.

Fevers of Unknown Origin

Lumbar PunctureFresh Sample of Urine and Measure Temperature

Vomiting

May Have Functional VomitingOn Some Occasions Observed to Induce the Vomiting

Final Caveats in the Diagnosis of Hysteria

Some Patients With Puzzling Organic Disorders, in Making the Rounds From Doctor to Doctor, Elaborate on or Exaggerate Their Organic Disorders in Desperation As They Try to Convince the Doctor of Their Illness.

Final Caveats in the Diagnosis of Hysteria

Patient May Display Both Organic and Functional Disease

Do Not Be ConfrontationalDon't Rush ThingsDo Not Attempt to Treat to "Speed Up" Recovery

Treat Causes, Not Effects

Similar for Chronic Pain Syndromes Which Represent Complicated Mixtures of Organic Disease, Functionally Overlay, Depression, and Hostility.

Never Diagnose a Functional Illness by Exclusion Because You Cannot Think of Anything Else. Call in a Consultant Who Just May Recognize the Smoldering Collagen Disease, Occult Carcinoma, Parasitic Infestation or Chronic Liver Abscess That You Didn't Even

Think About.

There Are More Things in Heaven and Earth, Horatio, Than Are Dreamt of in Your Philosophy.William Shakespeare

The Goals of the Physician

A Painless ExaminationA Complete CureLeaving No Blemish Behind