Hysteria

John O’Donovan

History of hysteria

• Conversion disorder • In general neurological type presentation

without evidence of a neurological cause. • The presentation tends to conform to ideas of

the patient about how parts of the body or mind malfunction. (patient’s concept of an illness)

History

• Ancient Greece, part of the Hippocratic Corpus delineating certain disease states including what we would now describe a panic attacks and also epilepsy as secondary to the uterus being misplaced. “hysterix pnix”

• Came into recent european writings with Cullen.

• 1600s possession by demons.

Posssession?

Salem Witchcraft Trials 1697

Sydenham from “discourse on hysteria” 1624-1694

• When the mind is disturbed by some grevious accident, the animal spirits run into disorderly motions; the urine appears sometimes limpid, and in great quantity; the sick person casts off all hope of recovery…. In the head the Apoplexy….., sometimes they are seized with convulsions that very much resemble the epilepsy… and are commonly called the suffocation of the womb; at other times they are miserably tormented with the hysterical clavus in which there is a most vehement pain in the head, which you may cover with your thumb…………

Charcot 1880s

made the link between paralysis and idea.

First noted by Reynolds

Freud: the basic concept of repression into the unconsious and the underlying battle between drives and aspects of the minds structures becomes apparent in a physical presentation.

WAR

American Civil War; “Da Costs syndrome” WW1- shellshock

2 schools of thought “psychological” versus “short sharp shock”

The army: “insufficient moral fibre” but yet set up military psychiatry.

Strongly urge all trainees to read the history of psychiatry in this period

Looking good Sigmund

Important to compare primary and secondary gain.

Primary gain is the resolution of the subconcious conflict with development of the symptom.

Secondary gain is a completely different process, sick role etc, nothing to do with Freudian dynamic theory.

Currently

ICD-10• Conversion is under dissociative

disorders• F44 “all tend to remit after a few weeks

or months”, really that’s news to me. • 44.0 dissociative amnesia • 44.1 dissociative fugue• 44.2 dissociative stupor• 44.3 trance and possession disorders• 44.5 dissociative convulsions• 44.6 dissociative anaesthesiae and

sensory loss• 44.7 mixed conversion• 44.8 others, includes Ganser’s syndrome • 44.81 multiple personality disorder

DSM-4 • Classified under

“somatoform disorders”• Note in ICD-10 F45 is

somatoform disorders

Common exam theme!

• Distinction between the following conversion/dissociation, somatization disorder, hypochondriacal disorder and malingering

• Conversion is classical neurological type presentation, post acute event, psychological trauma

• Somatisation is multiple physical ailments and presentations

• Hypochondriacal is concern with one or two serious ailments

• Malingering is production of symptoms for clear and immediate gain.

Ganser’s Syndrome

• First described in 1898, 3 prisoners in Halle by Sigbert Ganser.

• Approximate answers• Sometimes personal identity loss • Regarded often as a variant of malingering as

much as dissociative, classed under dissociative.

• Arguably very rare

Conversion disorder

• Not all that rare • Common enough in neurology wards• 5-10% of neurology OPD patients, no

neurological explanation for symptoms • Up to 33% of patient evaluated in specialist

centres for treatment refractory epilepsy have non epileptic seizures

• Younger patients 3:1 female to male as they get older becomes a 1:1 ratio.

Conversion disorder basics

• Sometimes there is a recent precipitant, sometimes there is not.

• Frequently it can be difficult to decide how much voluntary awareness is present and how much is unconcious

• There is an overlap with somatisation• There is marked cultural variation. • There is only very seldom an organic problem

when a good physician says that there is not.

Dissociative amnesia

• Loss of autobiographical memory • Anterograde memory preserved • No focal neurology • Note: the memory loss from ECT arguably

affects autobiographical memory• Kopelman has developed a psychological

schedule for autobiographical memory loss • Case reports of autobiographical memory loss

post epilepsy surgery

Dissociative stupor

• Unresponsive • Normal EEG • Walking, respiring etc • NOT CATATONIC

Dissociative anaesthesia or weakness

Neurological examination and investigations do not reveal a cause for symptoms. Presentation does not respect neuroanatomy

Hoover’s Sign

Other signs

• Give way weakness • Vibration sense splitting the midline• Wrong pattern of weakness • Inconsistent examination • Speed the patient up• For movement disorders, use entrainment

Astasia abasia

Psychogenic seizures

epilepsy• EEG changes • Frequently hurt• Events occur out of sleep • When alone • If tonic clonic can bite tongue,

sides of cheek, big lacerations• Prolactin elevated • Lasts a brief time • Nearly always responds to

treatment, BDZs and IV AED

NEAD• EEG normal during event• Can be hurt in event • Rarely out of sleep • With a wittness • Bites tip of tongue • Can last hours • Does not respond to

treatment, AEDs

NEAD

Epilepsy • History is normally very

clear• Personality Normal?• Frequently will have

psychiatric problems but different types of problems, depression.

NEAD• History is vague, does not

describe the seizure well.• Strong association with Axis

2 disordes, in particular BPD and childhood abuse

• Self harm other features of psychiatric illness

• Teddy Bears

Fugue

• Loss of memory and travel • Sometimes associated with alcohol • Some with psychosis • Some are probably transient global amnesia

which is not psychiatric

Others

• Blindness • Aphonia-note paradoxical adduction of vocal

cords• Dissociative identity disorder- hard to believe

that it truly exists, it is however in ICD-10.

Treatment

• Be clear about diagnosis in your own mind. • Non judgmental. • Explanation to patient. • Look for depression, TCAs are better. • Psychotherapy, different approaches CBT,

psychodynamic• Specialist in patient treatment units• Avoid excess investigations

Prognosis?

• Very few top class studies with sufficient length of follow up.

• My old boss who had perhaps 30 plus years as a consultant dealing with these patients felt that they frequently represented.

Prognosis

Good • Acute onset • Early presentation • well developed personality • Specialist treatment early• Is the natural course for

them to get well? • Psychologically minded.

Poor• Long standing problems • Personality disorder • “secondary gain”• Reluctance to understand

problem in psychological way.