Descriptive Psychopathology: The Signs and Symptoms of ...

180 Section 3: Examination domainsMany other classic symptoms of hysteria are shown to result from specific disease.At one time, Parkinson’s disease, St Vitus’ dance, tetanus and eclampsia wereconsidered neurotic disorders. 111 Denial of illness, la belle indifference, andhemianesthesia,classic signs of conversion, are associated with thalamic disease. Manynon-epileptic fits are in fact partial complex seizures identified by laboratory studies.Anatomically inconsistent pain patterns are often prominent early signs in multiplesclerosis, and astasia–abasia, the “classic” hysterical gait and walking difficulty, isassociated with dementia, 112 and midline cerebellar and corpus callosum lesions. 113Many examples of motor conversions and psychogenic movement disorder areunderstood as features of catatonia or specific neurologic disease. Patient 1.7, the78-year-old woman who was said to have psychogenic “confusion” and catatonia(diagnosed by a university hospital neurology team, and then a psychiatrist), wasfound to be in non-convulsive status epilepticus. Patient 4.1, the 56-year-old nursewho was said to have a psychogenic movement disorder (diagnosed by a psychiatricresident, his faculty supervisor, a neurologist, and several other psychiatry facultymembers), was found to have familial cerebellar–pontine degeneration.Patient 7.5 also illustrates the value of not assuming symptoms to be “psychogenic”even if they appear associated with so-called primary or secondary gain(psychological or tangible, respectively). 114Patient 7.5 115A 30-year-old woman was referred to a psychoanalyst by her primary carephysician because of neck and head pain of six months’ duration keeping herfrom going to work, and for which no medical cause was determined in acursory evaluation. She was pain-free most of the time, except when riding thecommuter train to work. The train ride took about 25min, and her pain beganshortly after she boarded and worsened as the train approached the terminusand her workplace, forcing her to return home. She had been at the job forabout six months, and found it “stressful”.Obtaining a careful history (the story of the illness), the psychoanalystdiscovered that by the time the patient boarded the train all the seats weretaken and she had to stand on the platform near the car exit, receiving the fullenergy of the car bouncing over the tracks. He surmised that the car’s up anddown movement affected a cervical spine abnormality leading to nerve rootinflammation and the pain. This was confirmed on CT scan and a neck braceworn during the commute resolved the patient’s difficulties.Patient 7.6 also illustrates the dangers of automatically accepting the patient’ssymptoms as “psychogenic” if they do not fit the examiner’s understanding ofneuroanatomy and function.