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Women who suffer injury at work or are involved in auto accidents may exhibit the same symptoms and signs of compensation neurosis as men but in our experience, do so infrequently Etiology and Pathogenesis Psychoanalytic theory, which holds that both conversion and dissociative symptoms are based on particular psychodynamic mechanisms, is impossible to af rm or refute While subject to some question of fabricated recall, we have been impressed at the high rate of childhood sexual abuse reported by women with severe monosymptomatic cases of hysteria or fugue states This conforms to some extent with psychoanalytic views but may not apply in classic hysteria Sociologic and educational factors are probably important, for it has been observed that hysterical women as a group tend to be less intelligent and less educated than nonhysterical women A genetic causation must also be considered Family studies have disclosed that about 20 percent of rst-degree relatives of female hysterics have the same illness, an incidence 10 times that in the general population This supports the idea that hysteria is a disease and not merely a surfacing of a basic personality disorder (see Goodwin and Guze) Whether conversion symptoms are consciously produced by the patient or arise unconsciously, without the patient s awareness, is a question that has been debated endlessly without resolution Babinski attributed the symptoms to hypersuggestibility In fact, he de ned hysteria as an illness whose symptoms could be induced (and removed) by suggestion There is strong evidence to support this idea, since most patients can be readily hypnotized and their symptoms temporarily eliminated by this procedure, or by an interview and examination under the in uence of midazolam The present authors place great weight on the importance of hypersuggestibility, in keeping with older studies that emphasized these patients unusual susceptibility to suggestion and hypnosis Interesting in this regard were the observations of Charcot s students, that on their wards the patients symptoms disappeared in his absence Some insights can be obtained from studies of functional imaging in hysterical paralysis (see also Chap 3) In general, the contralateral prefrontal cortex is suppressed when the patient with hysteria attempts to move a limb, suggesting to Spence and colleagues a choice of an active attempt not to move the limb However, the pattern of activation was quite different from volunteers who purposefully feigned paralysis and who did not demonstrate such reduced prefrontal activity As pointed out by Carothers and by Guze and colleagues, hysteria and sociopathy are closely related Hysteria is a disease of women and sociopathy mainly of men As restated by Cloninger and colleagues, they may constitute expressions of a single underlying variable This relationship is also supported by family studies First-degree male relatives of hysterical women have an increased incidence of sociopathy and alcoholism; among rst-degree female relatives of convicted male felons, there is an increased prevalence of hysteria Moreover, careful histories of sociopathic girls reveal that many of them develop the full syndrome of hysteria Women felons often present a mixed picture of hysteria and sociopathy, according to Cloninger and Guze Diagnosis The characteristic age of onset; the longitudinal history of recurrent multiple complaints, as outlined earlier; the attitude of the patient and the manner of presenting her symptoms; the incongruity of affect and clinical state; the discrepancy between the neurologic de cit and the signs on examination; the impossibility.

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of explaining the patient s signs on an anatomic or physiologic basis; and the absence of symptoms and signs of other medical and surgical disease will permit an accurate diagnosis in the majority of cases Certain tests designed to reveal normal functioning of a limb, of vision, and of gait have been mentioned There is a signi cant overlap of hysteria and other medical and neurologic diseases On record are numerous studies in which patients with an initial diagnosis of hysteria by general physicians were followed for many years Up to one third of them (less in most series) turned out eventually to have an organic condition which, in retrospect, explained the initial symptoms (Couprie et al) This emphasizes that the original clinical diagnosis of hysteria is often erroneous When the diagnostic criteria in these cases are closely analyzed, it becomes apparent that the diagnosis was made solely by the discrepancy method ie, the patient s symptoms or signs were not deemed to be credible manifestations of disease, based mainly on the clinical experience of the examiner Of course, this assumes that the examiner has a wide experience; unfortunately for the novice, many syndromes are unknown or incomprehensible However, when diagnosis is based on the totality of the clinical picture and not on the discrepancy method, it can be quite accurate The physician can be further reassured that in follow-up studies of patients with so-called conversion disorder (exclusive of pseudoseizures), virtually none develop a neurologic lesion that in retrospect was related to the initial episode as for example in the study by Stone and colleagues It is of interest that in the series cited, most patients had persistent functional disability from their conversion symptoms, even a decade later So-called projective tests (the Rorschach and Thematic Apperception Tests), which for a time were popular with dynamic psychiatrists, are not helpful in diagnosis and are now used very little The presence of extreme suggestibility and the tendency to dramatize symptoms as measured by one part of the Minnesota Multiphasic Personality Inventory and other psychometric tests is helpful in diagnosis but not pathognomonic of the disease; these traits appear under certain conditions in individuals who never develop hysteria Finally it should be reemphasized that single bouts of isolated hysterical paresis, blindness, and anesthesia are quite common in neurologic practice and do not presage a chronic hysterical illness The same is true for transient neurologic signs exhibited during the course of the examination, mainly pertaining to unusual or drifting sensory loss or asthenic weakness of a limb.

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