Diagnosis and management of hysteria

Patients with the diagnosis of hysteria are a perennial management problem for the nonpsychiatric physician. Hysteria is an operationally defined clinical entity characterized by onset before age 30 and by multiple medically unexplainable symptoms. Such patients should be differentiated from those with psychiatric disorders resulting in somatization, especially conversion disorders, and should be managed in such a way as to minimize sick-role incapacitation and reduce injudicious use of medication, medical procedures, and hospitalization.

Memories of positive experiences in the resolution of conflicts: illustrated in a case of hysteria

Clinical material from an analysis is used to illustrate the thesis that memories of positive experiences with significant figures of the past, like pathogenic memories, are displaced onto the analyst in the transference. It is suggested that such positive memories with their associated impulses, affects, and content become available and significantly operative in connection with and in response to interpretation and working through of pathogenic conflicts, especially in the transference. Memories of positive experiences appear to play a role in the resolution of conflicts and in the consequent analytic and therapeutic changes. Thus, just as there are repetitions of conflicted and pathogenic experiences, "negative repetitions," there are repetitions of positive experiences, "positive repetitions."

The impact of psychiatric intervention on patients with uncontrolled seizures

There is much evidence that emotional stess can trigger both neurogenic and hysterical seizures in susceptible patients. We reviewed out experience with 37 patients whose seizures appeared to be precipitated at times by emotional stress and had not been controlled by anticonvulsant medication alone. Approximately 70 per cent of patients demonstrated substantial improvement in seizure control after psychiatric treatment and maintained this improvement during follow-up. The findings of this study suggest that patient characteristics associated with better prognosis include normal intelligence, partial (as opposed to generalized) neurogenic seizures, a diagnosis of hysterical seizures, a less severely abnormal EEG, and being hypnotizable. After psychiatric treatment, 32 per cent of patients had their anticonvulsant medication reduced and another 16 per cent had it discontinued.

Ocular malingering and hysteria: diagnosis and management

Confronted with a claim of poor vision in the absence of any apparent pathology, the ophthalmologist must consider the possibility that the patient is malingering or hysterical. The authors define four categories of such patients, and recommend diagnostic approaches for each. Specific diagnostic tests are described, as are methods of managing patients once the diagnosis of malingering or hysteria has been made.

Hysterical sleep episodes as a manifestation of masked depression

A 55-year-old man suffered from compulsive sleep episodes as a manifestation of masked depression. Although the overt symptoms were conversive in nature, the treatment which finally focused on the depression was followed by disappearance of the patient's recurring sleeping spells for the first time in 4 years. Three methods were used: a) supportive psychotherapy, b) behavior therapy, and c) antidepressive medication. We conclude that the behavior treatment indirectly revealed the masked depression previously concealed by rigid defense mechanisms.

Hysterical psychosis and hypnotizability

The very existence of hysterical psychosis as a diagnostic entity has been questioned as part of the general difficulty in defining both hysteria and psychosis. However, several recent investigations have documented a syndrome that usually involves brief and intense periods of psychotic behavior, generally with graphic decompensation, severe environmental stress, and rapid recompensation, in individuals with other hysterical features. The authors assert that such a syndrome does exist as a clinical entity and that the differential diagnosis can be facilitated by using a standardized measure of hypnotic trance capacity. They hypothesize that patients with hysterical psychosis are highly hypnotizable, while those who are schizophrenic and psychotic have low hypnotizability. The authors review the literature and present two case examples.

The Burns' test in low back pain: correlation with the hysterical personality

Twenty-five postoperative lumbar laminectomy and diskectomy patients were administered the MMPI and evaluated by physical examination which included the Burns' Bench Test. In this test the patient is asked to kneel on a bench with knees and hips flexed and place his fingers on the floor. The kneeling position relieves stress on the low back and tension on the siatic nerve, so that patients with organic causes of low back pain are able to perform the test. Conversely, inability to perform the test is indicative of functional symptoms as in hysteria. All patients were males and the average age was 54. The average interval from surgery was 2 1/2 years. Sixty-seven per cent of those patients unable to perform the Burns' test were classified as hysterical on the basis of the MMPI, while 73% of patients classified as hysterical using the MMPI criteria failed to perform the Burns' test. The correlation between the Burns' test and hysteria as determined by the MMPI was 0.48. In terms of sensitivity and specificity, the sensitivity of the Burn's test in distinguishing patients with an hysterical MMPI was 73%. The specificity for normal subjects was 71%. The Burns' test is a useful clinical test for differentiating between organic and non-organic causes of low back pain. However, the test by itself should not be construed as an unequivocal measure of hysteria as defined psychologically by the MMPI. Failure to perform the test indicates a need for further psychological study.

Clinical aspects of the countertransference

Some of the ways in which countertransference reactions may manifest themselves are outlined in a series of case examples, which also illustrate how the therapist's recognition of the countertransference brought to light hitherto unrecognized transference resistances, thereby permitting their interpretation and progress in therapy. A number of technical steps for dealing with the countertransference are outlined, along with the reminder that while attention to the countertransference is important the therapist's principal focus must remain with the patient.

Pseudoepilepsy: a study in adolescent hysteria

Of 19 adolescents with diagnosed psychogenic seizures, 13 had hysterical convulsions and 4 had amnesiac fugues. Sixteen of the patients were given a diagnosis of hysterical neurosis; 2, process schizophrenia; and 1, borderline psychosis. Thirteen of the patients were initially diagnosed incorrectly as having epilepsy and were treated for an average of 15 months with anticonvulsant medication. The therapist should always consider the possibility of psychogenic factors in children and adolescents who suffer from seizures.