The term “hysteria” has largely been dropped from psychiatric parlance in favor of several other Diagnostic and Statistical Manual of Mental Disorders, fourth edition categories, but it continues to be used by neurologists as a descriptor for “functional” or “nonorganic” neurological disease. It is estimated that about one third of new neurological symptoms are regarded by neurologists as “not at all” or only “somewhat” explained by organic disease.

How often is there associated organic disease? Following analysis of a series of 112 patients, Slater (1962) concluded that one third had a hysterical conversion syndrome, as well as organic disease; one third were initially thought to have pure hysteria, of whom eight later developed organic disease; and one third had a psychiatric diagnosis such as schizophrenia, depression, or personality disorder. His findings were influential, and his conclusion that the diagnosis of hysteria was a disguise for ignorance and a fertile source of clinical error has influenced modern neurology.

The diagnosis of hysteria is therefore fraught with danger—not only may the diagnosis be plain wrong, but there is frequently a “kernel” (Charcot) of organic pathology that is overwhelmed by the psychiatric signs and symptoms. Approximately 15% of diagnosed conversion reactions subsequently prove to be due to missed neurological conditions.

These patients require extensive study to exclude an organic nidus, but if the same syndrome keeps repeating itself, the return on repeating the investigative studies is low. A good outcome is associated with a short history, but follow-up is necessary—conversion disorders do not protect the patient from developing other diseases.

Conversion reactions may involve any neurological subsystem, including movement, sensation, and cognitive intellectual abilities.

The term “hysteria,” based on the Egyptian theory of the wandering uterus, is credited to Hippocrates. Pierre Briquet (1776-1881) considered hysteria to be the product of suffering of the part of the brain destined to receive affective impressions and feelings (personnalite hysterique) and influenced Jean-Martin Charcot (1825-1893), who delivered his first lecture on hysteria, a lesson on hysterical contractures, at the Salpêtrière, in June of 1870. In the previous year, Charcot had heard a paper by Russell Reynolds at the British Medical Society meeting in Leeds, England, entitled “Paralysis, and Other Disorders of Motion and Sensation, Dependent on Idea.” With an influx of female patients to the neurology wards when a psychiatric ward in the condemned Saint Laure building was closed, Charcot devoted himself to the study of hysteria in his later years. His research and case demonstrations attracted many prominent physicians, including Adolf Meyer, James Jackson Putnam, and Sigmund Freud. The French school also included Charles Lasègue, Ernest Mesnet, and Paul Blocq, who wrote the seminal papers on astasia-abasia in 1888. Freud suggested that an unconscious conflict is symbolically converted into a somatic symptom.

The American Civil War prompted an appraisal of functional signs and symptoms in malingering soldiers trying to avoid the battlefield. Weir Mitchell (1829-1914) first encountered hysteria in these soldiers and subsequently developed his “rest cure” for patients with neurosis and hysteria in civilian practice. His therapeutic efforts would be viewed with distain today; he once remarked, “Yes, she will run out of the door in two minutes; I set her sheets on fire. A case of hysteria.” He described the rest cure as: “to lie abed half a day and sew a little, and read a little, and be interesting and excite sympathy, is all very well but when they are bidden to stay in bed a month, and neither to read, write nor sew, and to have one nurse—who is not a relative—then rest becomes for some women a rather bitter medicine and they are glad enough to accept the order to rise and go about when the doctor issues a mandate which has become pleasantly welcome and eagerly looked for.”

The crux of a diagnosis of hysteria is that the symptoms and physical signs do not correlate with known neurological damage patterns (Table 22.1).

“La belle indifference,” an apparent lack of concern with or about the nature and implications of the symptoms or disability, has no discriminatory value.

Although laterality has been suggested as an indicator for hysteria, when put to analysis there is only a slight left-sided preponderance of signs and symptoms (55% to 60%). Nonepileptic seizures are preponderantly right-hemisphere related—71% in one study.