Uncovering the etiology of conversion disorder: insights from functional neuroimaging

Conversion disorder (CD) is a syndrome of neurological symptoms arising without organic cause, arguably in response to emotional stress, but the exact neural substrates of these symptoms and the underlying mechanisms remain poorly understood with the hunt for a biological basis afoot for centuries. In the past 15 years, novel insights have been gained with the advent of functional neuroimaging studies in patients suffering from CDs in both motor and nonmotor domains. This review summarizes recent functional neuroimaging studies including functional magnetic resonance imaging (fMRI), single photon emission computerized tomography (SPECT), and positron emission tomography (PET) to see whether they bring us closer to understanding the etiology of CD. Convergent functional neuroimaging findings suggest alterations in brain circuits that could point to different mechanisms for manifesting functional neurological symptoms, in contrast with feigning or healthy controls. Abnormalities in emotion processing and in emotion-motor processing suggest a diathesis, while differential reactions to certain stressors implicate a specific response to trauma. No comprehensive theory emerges from these clues, and all results remain preliminary, but functional neuroimaging has at least given grounds for hope that a model for CD may soon be found.

Pediatric functional neurologic symptoms

Functional neurologic disorders (FND) of children have many similarities to those of adults, and there is a potential to learn much from the study of FND in children. In this chapter we discuss multiple aspects of pediatric FND. These include their frequency, historic features, the diagnosis, and controversies over the nature of FND and the "correct" name that should be used. We also discuss methods of informing the child and family of the diagnosis, treatment, and prognosis. FND of children typically affect girls in the 10-14-years age range. The presentation is often polysymptomatic, with pain and lethargy accompanying loss of motor function. A common situation is a perfectionistic child who has taken on too much in her academic, sporting, cultural, and social life. Some children respond readily to treatment, but others have a prolonged illness.

The Classification of Hysteria and Related Disorders: Historical and Phenomenological Considerations

This article examines the history of the conceptualization of dissociative, conversion, and somatoform syndromes in relation to one another, chronicles efforts to classify these and other phenomenologically-related psychopathology in the American diagnostic system for mental disorders, and traces the subsequent divergence in opinions of dissenting sectors on classification of these disorders. This article then considers the extensive phenomenological overlap across these disorders in empirical research, and from this foundation presents a new model for the conceptualization of these disorders. The classification of disorders formerly known as hysteria and phenomenologically-related syndromes has long been contentious and unsettled. Examination of the long history of the conceptual difficulties, which remain inherent in existing classification schemes for these disorders, can help to address the continuing controversy. This review clarifies the need for a major conceptual revision of the current classification of these disorders. A new phenomenologically-based classification scheme for these disorders is proposed that is more compatible with the agnostic and atheoretical approach to diagnosis of mental disorders used by the current classification system.

Panic and Culture: Hysterike Pnix in the Ancient Greek World

Starting perhaps in the second century BCE, and with Hippocratic precedent, ancient medical writers described a condition they called hysterike pnix or "uterine suffocation." This paper argues that uterine suffocation was, in modern terms, a functional somatic syndrome characterized by chronic anxiety and panic attacks. Transcultural psychiatrists have identified and described a number of similar panic-type syndromes in modern populations, and a plausible theory of how they work has been advanced. These insights, applied to the ancient disease of hysterike pnix, demystify the condition and illuminate the experience of the women who suffered from it.

Historical roots of histrionic personality disorder

Histrionic Personality Disorder is one of the most ambiguous diagnostic categories in psychiatry. Hysteria is a classical term that includes a wide variety of psychopathological states. Ancient Egyptians and Greeks blamed a displaced womb, for many women's afflictions. Several researchers from the 18th and 19th centuries studied this theme, namely, Charcot who defined hysteria as a "neurosis" with an organic basis and Sigmund Freud who redefined "neurosis" as a re-experience of past psychological trauma. Histrionic personality disorder (HPD) made its first official appearance in the Diagnostic and Statistical Manual of Mental Disorders II (DSM-II) and since the DSM-III, HPD is the only disorder that kept the term derived from the old concept of hysteria. The subject of hysteria has reflected positions about health, religion and relationships between the sexes in the last 4000 years, and the discussion is likely to continue.

Conversion Disorder- Mind versus Body: A Review

In this article, the authors accentuate the signs and symptoms of conversion disorder and the significance of clinical judgment and expertise in order to reach the right diagnosis. The authors review the literature and provide information on the etiology, prevalence, diagnostic criteria, and the treatment methods currently employed in the management of conversion disorder. Of note, the advancements of neuropsychology and brain imaging have led to emergence of a relatively sophisticated picture of the neuroscientific psychopathology of complex mental illnesses, including conversion disorder. The available evidence suggests new methods with which to test hypotheses about the neural circuits underlying conversion symptoms. In context of this, the authors also explore the neurobiological understanding of conversion disorder.

Conceptualizing splitting: On the different meanings of splitting and their implications for the understanding of the person and the analytic process

While "splitting" is a familiar concept, its meaning is not as self-evident as is commonly assumed. In different contexts, it refers to different phenomena and is supported by different understandings of psychic dynamics. In this paper, the author presents four different conceptualizations of splitting, which capture the essential aspects of contemporary psychoanalytic discourse on the concept. There is a dissociative kind of splitting, which involves splitting off, in the face of trauma, whole personalities, which to some extent remain accessible to consciousness; there is a disavowal kind of splitting that splits off our awareness of disturbing realities or their meanings in our efforts to avoid the inner restraints imposed by repression; and there are two forms of splitting of the object into good and bad-one focusing on the splitting of representations of the object due to ego weakness and environmental determinants, and the other on the splitting of the mind itself in a primarily destructive act aimed at sparing the good from the destructiveness of our death instinct. All four conceptualizations have their origins in Freud's writing and then are further developed in the work of later analysts. The author argues that understanding the nature of these various conceptualizations of splitting can contribute to analytic theory and practice. It also sheds light on the essential nature of analytic approaches and how they offer different perspectives on the unity and disunity of man's basic nature.

Investigating "mass hysteria" in early postcolonial Uganda: Benjamin H. Kagwa, East african psychiatry, and the Gisu

In the early 1960s, medical officers and administrators began to receive reports of what was being described as "mass madness" and "mass hysteria" in Tanganyika (now Tanzania) and Uganda. Each epidemic reportedly affected between three hundred and six hundred people and, coming in the wake of independence from colonial rule, caused considerable concern. One of the practitioners sent to investigate was Benjamin H. Kagwa, a Ugandan-born psychiatrist whose report represents the first investigation by an African psychiatrist in East Africa. This article uses Kagwa's investigation to explore some of the difficulties facing East Africa's first generation of psychiatrists as they took over responsibility for psychiatry. During this period, psychiatrists worked in an intellectual climate that was both attempting to deal with the legacy of colonial racism, and which placed faith in African psychiatrists to reveal more culturally sensitive insights into African psychopathology. The epidemics were the first major challenge for psychiatrists such as Kagwa precisely because they appeared to confirm what colonial psychiatrists had been warning for years-that westernization would eventually result in mass mental instability. As this article argues, however, Kagwa was never fully able to free himself from the practices and assumptions that had pervaded his discipline under colonial rule. His analysis of the epidemics as a "mental conflict" fit into a much longer tradition of psychiatry in East Africa, and stood starkly against the explanations of the local community.

The hysterical organization

The term hysteria has been used in the history of the psychoanalytical movement to describe a large variety of psychic modalities. What is the common denominator of the hysterias? The author suggests that ambivalence in relation to penetration in its passive form (vaginal desire), in its pregenital and genital valences, constitutes the essence of hysteria. It seems that the issue of hysteria thus configured finds its best resolution in the fantasy of an incorporeal penetration, which leads to orgasm, and spares one from the anxiety of destruction to the internal space as well as from the anxiety of guilt following the hoped for climax. The author is attempting to discern, by means of two case studies, how disembodied penetration, depending on whether it is fantasized or delusional, constitutes a solution, neurotic or psychotic respectively, to the issue of hysteria: the private theatre in neurosis, as well as the inhabited and influenced mind in psychosis (delusion of control), act as psychic figurations of vagina.

Demonic possession and the historical construction of melancholy and hysteria

Contrary to the often-voiced opinion that the birth of modern psychiatry should be regarded as a victory of enlightened science and rationality over outdated religious beliefs and ecclesiastical authority, it is argued in this article that the emergence of medical and psychiatric approaches to pathology in modernity takes place in the context of intensified religious life and mutual rivalry between the various religious denominations. Notably the two main types of demonological possession appearing in the context of Protestant and Catholic religious life, theological reflections and pastoral practices play a major role in the conceptualizations of melancholy and hysteria. The heritage of this can be viewed in the works of psychiatrists such as Charcot and Kraepelin, and also in Freud's psychoanalysis.

Differentiation between seizure and hysteria in a tenth-century persian text: Hidāyat of al-Akhawayni (d. 983 AD)

Although hysteria is associated largely with the nineteenth century, we find the subject treated in a tenth-century Persian medical text, the Hidayat al-Muta`allemin Fi al-Tibb [A Guide to Medical Learners] by al-Akhawayni Bukhari (d. 983 AD), a prominent physician in the Persian history of medicine. In this article, we discuss al-Akhawayni's views on seizure and hysteria and his differentiation between the two conditions, and we place it in a historical context.

Babinski the great: Failure did not deter him

Joseph Babinski (1857-1932) was born on November 17, 1857. He worked in a clinical arena dominated by Charcot and a focus on hysteria. His primary aim was in trying to find the reliable clinical signs to distinguish organic from non-organic disease of the nervous system. He was considered as masterly diagnostician, relying considerably less on neuropathological reports. Babinski's first attention to the reflex of the toes occurred during a chance observation of the contrasting responses between two female patients, one a hysteric and the other a hemiplegic. He first published description of his famous “sign” in 1896. Babinski's love for research works could be gauzed from his desire to publish and by the age of 27 years, he had to this credit, 12 important articles, mainly concerned with histological and neurological themes and one of his articles on the basic description of muscle spindles was considered to be a significant one. He was awarded the doctorate degree in 1885. Babinski introduced the concept of pithiatism, meaning “curable by suggestion.” He anticipated the emergence of neurosurgery in France and only 6 days prior to his death he is on record to have said that his most vital contribution to the cause of neurosciences was not the sign he described, but that he could goad Clovis Vincent and Martel to take up neurosurgery as a specialty.

Tests for malingering in ophthalmology

Simulation can be defined as malingering, or sometimes functional visual loss (FVL). It manifests as either simulating an ophthalmic disease (positive simulation), or denial of ophthalmic disease (negative simulation). Conscious behavior and compensation or indemnity claims are prominent features of simulation. Since some authors suggest that this is a manifestation of underlying psychopathology, even conversion is included in this context. In today's world, every ophthalmologist can face with simulation of ophthalmic disease or disorder. In case of simulation suspect, the physician's responsibility is to prove the simulation considering the disease/disorder first, and simulation as an exclusion. In simulation examinations, the physician should be firm and smart to select appropriate test(s) to convince not only the subject, but also the judge in case of indemnity or compensation trials. Almost all ophthalmic sensory and motor functions including visual acuity, visual field, color vision and night vision can be the subject of simulation. Examiner must be skillful in selecting the most appropriate test. Apart from those in the literature, we included all kinds of simulation in ophthalmology. In addition, simulation examination techniques, such as, use of optical coherence tomography, frequency doubling perimetry (FDP), and modified polarization tests were also included. In this review, we made a thorough literature search, and added our experiences to give the readers up-to-date information on malingering or simulation in ophthalmology.

German battle casualties: the treatment of functional somatic disorders during World War I

World War I witnessed the admission of large numbers of German soldiers with neurological symptoms for which there was no obvious organic cause. This posed a considerable challenge for the military and medical authorities and resulted in an active discussion on the etiology and treatment of these disorders. Current historiography is reliant on published physician accounts, and this represents the first study of treatment approaches based on original case notes. We analyzed patient records from two leading departments of academic psychiatry in Germany, those at Berlin and Jena, in conjunction with the contemporaneous medical literature. Treatment, which can be broadly classified into reward and punishment, suggestion, affective shock, cognitive learning, and physiological methods, was developed in the context of the emerging fields of animal learning and neurophysiology. A further innovative feature was the use of quantitative methods to assess outcomes. These measures showed good response rates, though most cured patients were not sent back to battle because of their presumed psychopathic constitution. While some treatments appear unnecessarily harsh from today's perspective and were also criticized by leading psychiatrists of the time, the concentration of effort and involvement of so many senior doctors led to the development of psychotherapeutic methods that were to influence the field of psychiatric therapy for decades to come.

Neuroinflammation, neuroautoimmunity, and the co-morbidities of complex regional pain syndrome

Complex Regional Pain Syndrome (CRPS) is associated with non-dermatomal patterns of pain, unusual movement disorders, and somatovisceral dysfunctions. These symptoms are viewed by some neurologists and psychiatrists as being psychogenic in origin. Recent evidence, however, suggests that an autoimmune attack on self-antigens found in the peripheral and central nervous system may underlie a number of CRPS symptoms. From both animal and human studies, evidence is accumulating that neuroinflammation can spread, either anterograde or retrograde, via axonal projections in the CNS, thereby establishing neuroinflammatory tracks and secondary neuroinflammatory foci within the neuraxis. These findings suggest that neuroinflammatory lesions, as well as their associated functional consequences, should be evaluated during the differential diagnosis of non-dermatomal pain presentations, atypical movement disorders, as well as other "medically unexplained symptoms", which are often attributed to psychogenic illness.

[A case of Psychogenous Crisis, a Linking Psychiatric Pathology]

Psychogenous seizures described by Charcot, are an entity that can be difficult to distinguish from epileptic seizures. 70% of these patients have an underlying psychiatric diagnosis. We describe the case of a female patient who was diagnosed with seizures for several years, poly-medicated, and included in the epilepsy surgery protocol for refractory patients. During the evaluation, a psychogenous origin was discovered for such crises. We analyzed the clinical criteria and laboratory tests that allow us to approach the differential diagnosis between both entities.

Functional (psychogenic) movement disorders

PURPOSE OF REVIEW

This review provides an overview of recent developments in diagnosis, pathophysiology, neuroimaging and management of functional (psychogenic) movement disorders (FMD).

RECENT FINDINGS

There has been increasing interest to study the underlying pathophysiology of FMD, which has resulted in a broadened disease model, taking neurobiologic and psychosocial factors equally into account. In this context, the term 'psychogenic' has been replaced by 'functional' movement disorders by many authors in the field to express the changing focus toward a multifactorial disease model. The need for establishing a positive diagnosis of FMD as opposed to providing a diagnosis of exclusion is increasingly recognized and reflected by the introduction of 'laboratory-supported' diagnostic criteria of FMD. Important advances have been made through behavioral, electrophysiological and neuroimaging studies, although the fundamental cause of FMD remains poorly understood. Of particular interest have been several reports on abnormal sensorimotor features and cortical inhibition in both organic and functional dystonia, highlighting possible shared traits of both conditions. In terms of treatment, recent studies have reported benefit from both psychiatric and physical therapy-based interventions.

SUMMARY

Increasing efforts have been made toward better understanding of FMD, and the disease model has been broadened to include neurobiologic and psychosocial factors. Laboratory-based diagnostic criteria have been established for many FMD to support the clinical diagnosis. To determine the most effective management strategies for FMD, a closer collaboration between neurologists and psychiatrists and intensified research efforts with prospective treatment trials are needed.

Current debates over nosology of somatoform disorders

There is a wide debate among the researchers and clinicians over the diagnostic categories subsumed under the rubric of somatoform disorders (SDs). Recent proposals vary from radical views that call for removing this category altogether to the conservative views that suggests cosmetic changes in the diagnostic criteria of SDs. We have the reviewed the relevant literature through PUBMED search supplemented with manual search on current concepts of SD.

The neurological manifestations of trauma: lessons from World War I

Changes in the clinical presentation of functional disorders and the influence of social and cultural factors can be investigated through the historical case notes from mental hospitals. World War I (WWI) was a potent trigger of functional disorders with neurological or psychiatric symptoms. We analysed 100 randomly selected case files of German servicemen admitted to the Department of Psychiatry of the Charité Medical School of Berlin University during WWI and classified them according to contemporaneous and retrospective modern diagnoses. We compared the clinical presentations with accounts in the German and British medical literature of the time. Most patients obtained the contemporaneous diagnosis of 'psychopathic constitution' or hysteria reflecting the general view of German psychiatrists that not the war but an individual predisposition was the basis for the development of symptoms. The clinical picture was dominated by pseudoneurological motor or sensory symptoms as well as pseudoseizures. Some soldiers relived combat experiences in dream-like dissociative states that partly resemble modern-day post-traumatic stress disorder. Most servicemen were classified as unfit for military service but very few of them were granted compensation. Severe functional disorders of a neurological character could develop even without traumatic exposure in combat, which is of interest for the current debate on triggers of stress disorders. The high incidence of pseudoseizures accords with the psychiatric literature of the time and contrasts with accounts of war-related disorders in Britain. The tendency of German psychiatrists not to send traumatised servicemen back to active duty also distinguished between German and British practice. Our data contribute to the debate on the changing patterns of human responses to traumatic experience and their historical and social context.

Malingering or simulation in ophthalmology-visual acuity

Simulation can be defined as malingering, or sometimes functional visual loss (FVL). It manifests as either simulating an ophthalmic disease (positive simulation), or denial of ophthalmic disease (negative simulation). Conscious behavior and compensation or indemnity claims are prominent features of simulation. Since some authors suggest that this is a manifestation of underlying psychopathology, even conversion is included in this context. In today's world, every ophthalmologist can face with simulation of ophthalmic disease or disorder. In case of simulation suspect, the physician's responsibility is to prove the simulation considering the disease/disorder first, and simulation as an exclusion. In simulation examinations, the physician should be firm and smart to select appropriate test(s) to convince not only the subject, but also the judge in case of indemnity or compensation trials. Almost all ophthalmic sensory and motor functions including visual acuity, visual field, color vision and night vision can be the subject of simulation. Examiner must be skillful in selecting the most appropriate test. Apart from those in the literature, we included all kinds of simulation in ophthalmology. In addition, simulation examination techniques, such as, use of OCT (optical coherence tomography), frequency doubling perimetry (FDP), and modified polarization tests were also included. In this review, we made a thorough literature search, and added our experiences to give the readers up-to-date information on malingering or simulation in ophthalmology.

Psychogenic movement disorders and motor conversion: a roadmap for collaboration between neurology and psychiatry

BACKGROUND

There are a host of vague terms to describe psychologically-mediated symptoms that mimic neurological disease, such as "functional," "non-organic," "psychogenic," or "medically unexplained." None of these terms has a direct translation in psychiatric classification, and psychiatrists are often faced with patients who do not believe in a psychological origin for their symptoms.

OBJECTIVE

Within the framework of psychogenic movement disorders, we discuss the roadblocks to effective collaboration and treatment in these patients and the current state of the literature regarding diagnosis and treatment.

RESULTS

We describe the approach to these patients from the perspective of neurology and psychiatry, illustrating the differences in terminology and categorization.

CONCLUSION

Psychogenic movement disorders represent a unique opportunity for these fields to collaborate in the care of a potentially curable but significantly disabling disorder.

Limits to truth-telling: neurologists' communication in conversion disorder

OBJECTIVE

Neurologists face a dilemma when communicating with their conversion disorder patients - whether to be frank, and risk losing the patient's trust, or to disclose less, in the hope of building a therapeutic relationship. This study reports how neurologists in the UK described dealing with this dilemma in their practice.

METHODS

Practicing consultant neurologists from an NHS region were recruited by snowball sampling. Twenty-two of 35 consultants in the region were interviewed in depth, and the interviews qualitatively analysed.

RESULTS

The neurologists were reluctant to disclose conversion disorder as a differential diagnosis until they were certain. They were guided by the receptivity of their patients as to how psychological to make their eventual explanations, but they did not discuss their suspicions about feigning. They described their communications as much easier now than they had seen in training.

CONCLUSION

Neurologists adapt their disclosure to their patients, which facilitates communication, but imposes some limits on truth-telling. In particular, it may sometimes result in a changed diagnosis.

PRACTICE IMPLICATIONS

An optimum strategy for communicating diagnoses will need to balance ethical considerations with demonstrated therapeutic benefit.

Systematic enhancement of functioning as a therapeutic technique in conversion disorder

To explicitly outline a therapeutic technique for symptom removal in conversion disorder. We describe one patient with conversion dumbness and another with conversion paraplegia. The first patient was successfully treated in a single session, and the second was successfully treated across two weeks, both using systematic enhancement of functioning as a technique for symptom removal. This technique encourages the patient to express the desired behavior to whatever extent possible; subsequently, the patient is encouraged to gradually amplify the response until normal levels of functioning are achieved. The technique outlined is simple and practical but nevertheless receives no mention in conversion disorder literature. The technique can be applied to any situation in which behavioral amplification is desired.

Streamlined classification of psychopathological hand disorders: A literature review

In the surgical hand clinic, psychopathological hand disorders can be sorted into one of the following four categories: (1) factitious wound creation and manipulation; (2) factitious edema; (3) psychopathological dystonias, and (4) psychopathological sensory abnormalities and psychopathological Complex Regional Pain Syndrome. This article introduces these four categories. Pertinent literature that includes descriptions of each category's syndromes and diseases, demographic and psychological profiles, differential diagnoses, and appropriate treatment recommendations is reviewed.

Hysteria and catatonia as motor disorders in historical context

It is difficult to imagine motor symptoms in psychiatry as different as hysteria and catatonia. The mechanism of hysteria is presumed to be psychogenic, while catatonia has always been considered to be among the most organic syndromes in psychiatry. Yet hysteria and catatonia have historically been regarded as allied conditions, an observation borne out by recent developments in neuroscience as well as by a growing awareness that the presentation of both conditions has changed over the years. In hysteria, the main shift has been from motor symptoms to sensory complaints such as chronic fatigue; in catatonia, the major change has been the virtual disappearance of negativistic or oppositional behaviour. It is possible that catatonia as well as hysteria may be responsive to changing cultural norms.

Conversion disorder: towards a neurobiological understanding

Conversion disorders are a common cause of neurological disability, but the diagnosis remains controversial and the mechanism by which psychological stress can result in physical symptoms "unconsciously" is poorly understood. This review summarises research examining conversion disorder from a neurobiological perspective. Early observations suggesting a role for hemispheric specialization have not been replicated consistently. Patients with sensory conversion symptoms have normal evoked responses in primary and secondary somatosensory cortex but a reduction in the P300 potential, which is thought to reflect a lack of conscious processing of sensory stimuli. The emergence of functional imaging has provided the greatest opportunity for understanding the neural basis of conversion symptoms. Studies have been limited by small patient numbers and failure to control for confounding variables. The evidence available would suggest a broad hypothesis that frontal cortical and limbic activation associated with emotional stress may act via inhibitory basal ganglia-thalamocortical circuits to produce a deficit of conscious sensory or motor processing. The conceptual difficulties that have limited progress in this area are discussed. A better neuropsychiatric understanding of the mechanisms of conversion symptoms may improve our understanding of normal attention and volition and reduce the controversy surrounding this diagnosis.

Progress in understanding conversion disorder

Conversion disorder has a history that may reach back into antiquity, and it continues to present a clinical challenge to both psychiatrists and neurologists. This article reviews the current state of knowledge surrounding the prevalence, etiology, and neurobiology of conversion disorder. There have been improvements in the accuracy of diagnosis that are possibly related to improved technologies such as neuroimaging. Once the diagnosis is made, it is important to develop a therapeutic alliance between the patient and the medical team, and where comorbid psychiatric diagnoses have been made, these need to be adequately treated. While there have been no formal trials of medication or psychoanalytic treatments in this disorder, case reports suggest that a combination of antidepressants, psychotherapy, and a multidisciplinary approach to rehabilitation may be beneficial.

Symptoms and the perception of disease

Any symptom represents a perception of an abnormal internal body state. The threshold for perceiving the internal body state as abnormal varies and depends particularly on psychological influences. As a result, a symptom can either reflect pathology, whether serious or not, or be generated wholly psychologically. Intuition allowing discrimination between these possibilities is central to the physician's art. Particular difficulty arises in differentiating between those psychologically generated symptoms which are produced unconsciously, often as a result of anxiety or depression, and those that constitute deliberate deception. Such malingering has the unstated intent of accessing a secondary gain, such as welfare benefit. The art of diagnosis includes estimation of whether symptoms resonate with known pathophysiological processes, using history-taking as a story which unfolds logically towards a diagnosis, assessing how a patient reacts to their symptoms compared to neutral matters, detecting exaggeration or falsification, and documenting evidence of psychologically generated abnormalities during examination. Scientific ability is only one of the attributes of a good diagnostician; equally important are abilities to notice things, to weigh up human nature and to recognise dilemmas. Our procedures for selecting medical students and physicians need to assess these skills as well as scientific qualifications.

Axel Munthe's The story of San Michele revisited

This article provides a review of Axel Munthe's best-selling medical novel, The Story of San Michele, with particular reference to the light it sheds on late nineteenth and early twentieth century medicine.

A patient who changed my practice

The patient described in this paper expressed classical depressive delusions. However after her statements of doom she would grin and giggle. The author, as a young psychiatrist, assumed that she was not seriously depressed. Shortly afterwards the patient drowned herself. In restrospect the baby had been thrown out with the bathwater. Doctors may be too ready to assume that the patient is making it all up.

DISABILITY ASSOCIATED WITH SO-CALLED HYSTERICAL AMBLYOPIA

Objectives: To elucidate the clinical condition which is associated with non specific visual field loss in children: so called, Hysterical Amblyopia.

Materials and Method: 25 children with visual field defect were assessed by means of a proforma questionnaire which scored their disability. The results obtained from these children were compared with the results of the questionnaire being applied to 95 school children, ages 10 - 12 years, from the local primary school.

Results: In nearly all the symptoms elucidated by the questionnaire, the children with the visual field loss were much more affected than the control group. Statistical analysis rated the findings as highly significant.

Conclusion: The presence of concentric narrowing of the visual fields indicates that the visually affected children are likely to be beset by many other ailments: such as headaches, blurred vision, photophobia, light headedness, poor concentration, personality defect, restlessness and growing pains.

Hysteria and conversion in the ojibway patient: cross-cultural psychiatry for the family physician

Case examples of hysterical coma and paralysis in two Ojibway patients are used to introduce a discussion of conversion symptoms. Somatoform disorders are described using the criteria of the Diagnostic and Statistical Manual of Mental Disorders, third edition; these are then applied to hysteria in the Native American patient. The authors discuss the cultural context of conversion symptoms in this population and describe guidelines for the provision of culturally sensitive therapy by the family physician.