Psychosomatics 49:176-a-177, April 2008
doi: 10.1176/appi.psy.49.2.176-a
© 2008 Academy of Psychosomatic Medicine
Hysteria and Technology: Was Eliot Slater Right? • Case Report
François J. Sirois, M.D., Dept. of Psychiatry Laval Hospital 2725 Chemin Ste-Foy Ste-Foy, Quebec G1V 4G5 Canada
TO THE EDITOR: The British psychiatrist Eliot Slater proposed that hysteria was a misnomer to "mystify" an unrecognized physical illness. Should we conclude that modern technology would render him correct in some cases? The following clinical vignette raises the issue once again and discusses the weight of positive psychological signs in such a context.
A 58-year-old man came to the emergency room because of chest pain and dyspnea. Upon being given a small dose of narcotic analgesia, he developed weakness in both his left arm and leg. On examination, he was found to have some spasms in the lower extremities and possible urinary retention. Cardiac and pulmonary evaluations were normal. The patient was oriented, and sensorium was clear. Neurological examination was otherwise within normal limits. Affect was rather shallow, slightly optimistic, and without anxiety for his current situation. The patient’s father had just died in the previous 48 hours, and his mother had been admitted to the hospital within the last few days for a fractured hip. The patient had a history of previous anxiety crisis, and he reported having marital difficulties with his second wife; he said she scorned him for his erectile difficulties, and, thus, he could not enjoy his early retirement from civil service.
The diagnosis was unclear, and the patient was admitted. The clinical situation lumping changing neurological symptoms, a rather discordant affect, and a significant psychosocial context prompted a psychiatric consultation while the medical workout was undertaken. The patient insisted he could not walk, but, when asked, would refuse to try. He was lying in bed in a curious fashion, his legs wide-open as if in a gynecological position, heartily smiling at his situation, explaining how he did not need to be at the funeral parlor because he had made a video of his father’s life for his family. There was no evidence of depression; sensorium was clear, and verbal contact was adequate. Absence of anxiety about his condition was noted; his mood was akin to "la belle indifference." Expansivity was noted in verbal contact but did not affect his general demeanor, and signs of hypomania, such as explicitly euphoric mood, pressured speech, irritability, or restlessness were absent. Diagnosis compatible with conversion hysteria was contemplated pending further investigation.
His temperature at admission was 38.4°C (101.1°F). Cerebral tomodensitometry was normal. Lumbar puncture was unremarkable except for a slightly elevated protein level (55 mg/dL; normal: 0.09 mg/dL–40 mg/dL). Later viral serology was negative. A neurological consultation suggested transverse myelitis. Magnetic resonance imaging showed positive findings at C6–T2, documenting the diagnosis. The patient was put on a 10-day course of corticosteroids, and regained some walking ability, but kept urinary retention, requiring bladder catheterization.
His psychic picture remained stable and unchanged; further probing suggested that it could be indicative of hypomanic character traits, but the lack of concern about his current disability remained conspicuous; the patient remained blatantly optimistic. He was subsequently transferred to a rehabilitation center.
Discussion
When Slater delivered his speech at Queen Square 40 years ago, such a patient might have been diagnosed and discharged as a case of conversion hysteria. Current developments in technological devices do not render the diagnosis of hysteria obsolete but reduce the percentage of "false positive" cases. Yet the peculiar psychological presentation was observed by various people and should be accounted for. "Comorbidity" is an easy way out, but it begs the question. "Adjustment disorder" implies distress or impairment in social functioning, according to DSM–IV, but it could be understood as an overcompensation of character mechanisms; hence, the tendency to confuse the disease symptoms with the person presenting with them.
REFERENCES
- Slater E: Diagnosis of hysteria. BMJ 1965; 1(5447):1395–1399[Medline]
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