Today hysteria is known by the more palatable but still inaccurate moniker “conversion disorder.” It manifests acutely in the form of blindness, paralysis, even coma, with no apparent organic disease. Sigmund Freud believed that the hysterical mind converts some psychic trauma into a physical malady that will both garner sympathy and allow the sufferer to hide from her problems behind a shield of illness. Decades before Freud, the great French neurologist Jean-Martin Charcot suggested that hysteria was indeed an organic brain illness, not the product of a disturbed or demon-possessed mind, but Freud’s explanation gained wider acceptance.
Although many hysterics complain of mental distress (like Rachel’s boyfriend woes), recent neurophysiological evidence from PET scans and functional MRIs suggests that the malady may be akin to a seizure initiated by the frontal lobes, and so is a condition of the brain as well as the mind. Some people may have a vulnerability to this kind of response to stress. Thus Charcot was probably right (he usually was), and Freud was probably wrong (no surprise there either).
The cardinal sign of hysteria—indifference to an obviously crippling neurological predicament—is not entirely reliable. I once cared for a teenager who was suddenly struck blind. Because she seemed apathetic about her condition, she was mistakenly given a diagnosis of hysteria. In fact, she was both blind and apathetic because of a brain tumor. Nevertheless, indifference is still a useful clue, particularly when the physical examination is normal. Rachel’s preserved reflexes, good leg tone, downward Babinski sign, and preserved sensation were all inconsistent with known organic causes of sudden paraplegia (paralysis in both legs). Her lack of pain also made other causes like a ruptured disk, brain hemorrhage, or spinal abscess highly unlikely. Her nonchalance was simply icing on the diagnostic cake.
Conversion paralysis is very different from willful malingering because the hysterical patients really believe they cannot move. I have seen inexperienced physicians, anxious to expose a faker, injure people by placing clamps on their fingers or plunging needles deep into thigh muscles, only to be astounded and mortified when patients make no attempt to pull away. So I was gentle with Rachel, both physically and verbally.
I told her that most likely nothing serious was going on and that she probably had a “vitamin deficiency.” I instructed the nurses to infuse a liter of intravenous nutrients. The solution’s impressive amber hue suggests to the patient that some “real medicine” is being administered. This is one aspect of hysterical paralysis that still smacks of a psychiatric origin: Patients must be convinced that they are being treated as if they have an organic disease. Simply telling them they are imagining things doesn’t work very well.
There is an old adage: Neurology is what you do while you are waiting for the films to be developed. Physicians rely too heavily on imaging machines, and I saw no urgent need for scanning this patient. Her examination and history told her story well enough. True, the doctor must always rule out physical illness before diagnosing conversion syndrome, but in Rachel’s case, infusing some vitamins could be done in the time it took to fire up a cold MRI machine. By then I would know.
Twenty minutes after the infusion ended, Rachel’s legs roared to life, and she walked out the door. I went home, tired but happy in the knowledge that I hadn’t allowed a single freakish spasm of a young woman’s brain to land her in the poorhouse or in the psychiatric ward.
